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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/embryologyanatomOOcull 


OTHER  BOOKS 

BY 

THOMAS  S.  CULLEN 


Cancer  of  the  Uterus.  Large  oc- 
tavo of  693  pages,  with  310  colored 
and  half-tone  text-cuts  and  11  litho- 
graphs in  colors.  Cloth,  $7.50  net ; 
Half  Morocco,  $8.50  net. 

Adenomyoma    of    the    Uterus. 

Large  octavo  of  270  pages,  illus- 
trated. Cloth,  #5.00  net;  Half  Mo- 
rocco, $6.50  net. 

WITH  HOWARD  A.  KELLY 

Myomata  of  the  Uterus.     Large 

octavo  of  723  pages,  with  388  illus- 
trations, 19  in  colors.  Cloth,  $7.50 
net ;  Half  Morocco,  $9.00  net. 


EMBRYOLOGY,  ANATOMY,  AND  DISEASES 


OF  THE 


UMBILICUS 

TOGETHER  WITH 

DISEASES  OF  THE  URACHUS 


BY 

THOMAS  STEPHEN  CULLEN 

Associate  Professor  of  Gynecology  in  the  Johns  Hopkins  University 
Assistant  Visiting  Gynecologist  to  the  Johns  Hopkins  Hospital 


ILLUSTRATED 

BY 

MAX  BRODEL 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1916 


Copyright,  1916,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 


To  My  Mother 
MARY   CULLEN 

Daughter  of  the  late  Rev.  Thomas  and  Mary  Greene 

Born  on  July  12,  1841,  at  Polminick,  near 

Penzance,  Cornwall,  England 

THIS    BOOK 

is  affectionately  dedicated 


PREFACE 


During  the  summer  of  1904  I  saw  a  case  of  cancer  of  the  umbilicus  with  Dr. 
Jacob  L.  Winner.  Up  to  that  time  I  had  thought  that  hernia  was  practically  the 
only  lesion  to  be  noted  in  this  locality.  The  patient  did  well  for  a  time,  but  later 
large  intra-abdominal  tumors  could  be  felt  and  finally  he  died.  Xo  autopsy  was 
obtained.  Histologic  examination  of  the  umbilical  growth  showed  that  it  was  an 
adenocarcinoma. 

I  was  at  a  loss  to  explain  the  presence  of  glands  in  this  position,  and  a  cursory 
examination  of  the  text-books  failed  to  elucidate  the  matter.  I  could  not  rid  my- 
self of  the  desire  to  find  out  definitely  just  how  an  adenocarcinoma  could  exist  in  the 
umbilicus,  and  several  years  later,  when  other  and  more  pressing  problems  had  been 
completed,  I  carefully  searched  the  literature  for  cases  of  cancer  of  the  umbilicus 
and  was  amazed  to  find  the  records  of  many  instances. 

In  the  majority  of  the  cases  the  umbilical  growth  was  secondary  to  a  cancer  of 
the  stomach,  gall-bladder,  intestine,  or  ovary.  Cases  of  primary  adenocarcinoma 
and  of  squamous-cell  carcinoma  of  the  umbilicus  occur,  but  they  are  very  rare. 

During  this  study  I  encountered  a  wealth  of  material  dealing  with  the  omphalo- 
mesenteric duct.  We  have  long  been  familiar  with  Meckel's  diverticulum,  but  two 
facts,  that  the  omphalomesenteric  duct  may  be  patent  throughout  its  entire  extent 
at  birth,  and  that  remnants  of  the  outer  end  of  the  duct  may  give  rise  to  the  small 
umbilical  polyps  sometimes  noted  after  the  cord  drops  off,  have  not  been  commonly 
appreciated. 

The  literature  is  rich  in  records  of  devastating  infections  that  prevailed  before  the 
era  of  asepsis.  These  occurred  generally  in  hospitals,  and  most  often  when  an  epi- 
demic of  puerperal  sepsis  was  rampant  among  the  mothers.  The  descriptions  of 
some  of  them  are  intensely  graphic,  and  from  the  detailed  reports  of  the  individual 
cases  one  can  obtain  a  wonderful  picture  of  the  terminal  infections  occurring  in  these 
infants. 

I  found  a  somewhat  extensive  literature  on  dermoids  of  the  umbilicus,  but  on 
analyzing  the  cases  was  obliged  to  conclude  that  the  majority  of  these  growths 
represented  nothing  more  than  inflammations  due  to  irritation  exerted  by  an  um- 
bilical concretion.  It  was  the  presence  of  caseous  material  and  the  admixture  of 
wool  from  the  patient's  clothing  that  had  led  to  the  erroneous  diagnosis. 

I  found  records  of  cases  of  Paget's  disease,  diphtheria,  and  syphilis  of  the  um- 
bilicus. There  is  also  an  extensive  literature  on  the  escape  of  intra-  and  extra- 
abdominal  fluid,  usually  pus,  through  the  umbilicus,  and  many  cases  of  umbilical 
fistula  are  recorded. 

Many  umbilical  tumors  have  been  reported,  some  benign,  others  malignant. 
I  was  especially  interested  in  one  group  of  cases.  These  tumors  were  small;  they 
always  occurred  in  women;  they  tended  to  swell  at  the  menstrual  period,  and  some 


XU  PREFACE 

urachus  have  been  collected,  the  cases  classified,  and  the  appropriate  methods  of 
treatment  outlined.  I  trust  that  this  work  may  help  the  general  practitioner,  the 
pediatrician,  and  the  surgeon  to  treat  more  satisfactorily  lesions  of  this  heretofore 
relatively  unknown  region,  unknown,  although  up  to  the  dajr  of  birth  it  is  on  the 
main  highway  between  the  mother  and  the  child. 

Thomas  S.  Cullen. 
The  Johns  Hopkins  Hospital,  May,  1916. 


CONTENTS 

Chapter  Page 

I.  Embryology  of  the  Umbilical  Region 1 

II.  Anatomy  of  the  Umbilical  Region 34 

III.  Umbilical  Infections  in  the  Xew-borx 70 

IV.  Umbilical  Hemorrhage 106 

V.  Granulation  Tissue  or  Granuloma  of  the  Umbilicus 116 

VI.  Remnants  of  the  Omphalomesenteric  Duct US 

VII.  Congenital  Polyps;  Fistul.e  or  Cystic  Dilatations  at  the  Umbilicus;  with 
a  Mucosa  More  or  Less  Similar  to  that  of  the  Pyloric  Region  of  the 
Stomach,  and  Secreting  an  Irritating  Fluid  Bearing  a  Marked  Re- 
semblance to  Gastric  Juice.     Persistence  of  the  Outer  Portion  of  the 

Omphalomesenteric  Duct 144 

VIII.  Meckel's  Diverticulum 159 

IX.  Intestinal  Cysts U  4 

X.  A  Patent  Omphalomesenteric  Duct •  •    188 

XL  The  Patent  Omphalomesenteric  Duct  (Continued) 214 

XII.  Prolapsus  of  the  Bowel  through  a  Patent  Omphalomesenteric  Duct 222 

XIII.  Cysts  in  the  Abdominal  Wall  Due  to  Remnants  of  the  Omphalomesenteric 

Duct 238 

XIV.  Persistence  of  the  Omphalomesenteric  Vessels 242 

XV.  Umbilical  Concretions  Associated  with  Inflammatory  Changes  in  the  Ab- 
dominal Wall 247 

XVI.  Abscess  in  the  Subumbilical  Space 262 

XVII.  Paget's  Disease  of  the  Umbilicus 26S 

XVIII.  Diphtheria  of  the  Umbilicus  .     Syphilis  of  the  Umbilicus;    Tuberculosis 

of  the  Umbilicus;  Atrophic  Tuberculid  commencing  at  the  Umbilicus  .  .   277 
XIX.  The  Escape  of  Retroperitoneal  and  Abdominal  Fluid  from  the  Umbilicus; 
the  Opening  of  an  Appendix  Abscess  at  the  Umbilicus.     Abscess  of  the 
Liver  Opening  at  the  Umbilicus;    Peritonitis  with  the  Escape  of  Pus 
from  the  Umbilicus;  the  Piecemeal  Removal  of  a  Suppurating  Ovarian 

Cyst  through  the  Umbilicus 287 

XX.  Fecal  Fistula  at  the  Umbilicus 309 

XXI.  The  Escape  of  Round  Worms  from  the  Umbilicus 32S 

XXII.  The  Escape  of  Various  Foreign  Substances  from  the  Umbilicus 337 

XXIII.  Umbilical  Tumors 351 

XXIV.  Adenomyoma  of  the  Umbilicus 373 

XXV.  Carcinoma  of  the  Umbilicus 400 

XXVI.  Sarcoma  of  the  Umbilicus 449 

XXVII.  Umbilical  Hernia 459 

XXVIII.  The  Urachus 481 

XXIX.  Congenital  Patent  Urachus 487 

XXX.  Remnants  of  the  Urachus 515 

XXXI.  Urachal  Remnants  Producing  Tumors  between  the  Umbilicus  and  Symphy- 
sis     526 

xiii 


XIV  CONTENTS 

Chapter  Page 

XXXII.  Large  Urachal  Cysts 539 

XXXIII.  Abscesses  in  the  Anterior  Abdominal  Wall  between  the  Umbilicus  and 

Symphysis  Due  to  Infection  of  Urachal  Remains  or  of  Urachal  Cysts    . .   567 

XXXIV.  Urachal  Cavities  between  the  Symphysis  and  Umbilicus  Communicating 

with  the  Bladder  or  Umbilicus  or  with  Both 578 

XXXV.  Acquired  Urinary  Fistula  at  the  Umbilicus 607 

XXXVI.  Urachal  Concretions  and  Urinary  Calculi  Associated  with  Urachal 

Remains 620 

XXXVII.  Malignant  Changes  in  the  Urachus 628 

XXXVIII.  Bleeding  from  the  Urachus  into  the  Bladder 647 

XXXIX.  Tuberculosis  of  the  Patent  Urachus 649 

Index  of  Names 655 

Index   667 


LIST  OF  ILLUSTRATIONS 


Fig.  Page 

1.  Sagittal  Section  Showing  a  Very  Early  Stage  in  the  Formation  of  the  Umbilicus 

and  allantois 2 

2.  A  More  Advanced  Stage  in  the  Formation  of  the  Umbilical  Region 2 

3.  A  Composite  Picture  Showing  the  Formation  of  the  Umbilicus  in  an  Embryo 3 

4.  A  Diagrammatic  Representation  of  a  Human  Embryo,  about  3.5  mm.  Long,  Show- 

ing the  Effect  of  the  Expanding  Amnion  upon  the  Yolk-sac  and  Body-stalk  ...       4 

5.  Sagittal  View  of  a  Human  Embryo  5  mm.  in  Length 5 

6.  Anterior  View  and  Transverse  Section  of  a  Human  Embryo  7  mm.  Long,  Showing 

the  Umbilical  Region 6 

7.  Sagittal  Section  of  the  Umbilical  Region  in  an  Embryo  7  mm.  in  Length 7 

8.  Sagittal  View  of  the  Umbilical  Region  of  a  Human  Embryo  10  mm.  in  Length 8 

9.  Graphic  Reconstruction  of  the  Umbilical  Cord  of  a  Human  Embryo  12.5  mm.  in 

Length 9 

10.  Anterior  View  of  the  Umbilical  Cord  of  a  Human  Embryo  18  mm.  in  Length 10 

11.  Sagittal  Section  of  the  Umbilical  Region  in  a  Human  Embryo  23  mm.  in  Length  ..  11 

12.  A  Graphic  Reconstruction  of  the  Umbilical  Region  of  a  Human  Embryo  3  cm. 

Long 12 

13.  Sagittal  Section  of  the  Umbilical  Region  in  a  Human  Embryo  4.5  cm.  in  Length  ..     13 

14.  A  Graphic  Reconstruction  of  the  Umbilical  Region  of  a  Human  Embryo  4.5  cm. 

in  Length  as  Viewed  from  within  the  Abdomen 14 

15.  Sagittal  View  of  a  Graphic  Reconstruction  of  the  Umbilical  Region  of  a  Human 

Embryo  5.2  cm.  in  Length 15 

16.  Intra-abdominal  View  of  the  Umbilical  Region  of  a  Human  Embryo  6.5  cm.  in 

Length 17 

17.  Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  7.5  cm.  Long  .  .     18 

18.  Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  9  cm.  in 

Length 18 

19.  Intra-abdominal  View  of  the  Umbilical   Region  in  a  Human  Embryo  10  cm.  in 

Length 19 

20.  Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  12  cm.  Long  . .     19 

21.  Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  12  cm.  in 

Length 20 

22.  Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  12  cm.  in 

Length 21 

23.  Cross-section  of  the  Umbilical  Cord  at  the  Umbilicus  in  a  Human  Embryo  12  cm. 

in  Length 22 

24.  Internal  View  of  the  Umbilical  Region  in  a  Human  Embryo  15  cm.  Long 23 

25.  A  Composite  Representation  of  Abnormal  Umbilical  Structures,  Based  on  the 

Work  of  Keibel,  Lowy,  and  Others 24 

26.  A  Composite  Representation  of  Abnormal  Umbilical  Structures,  Based  on  the 

Work  of  Keibel,  Lowy,  and  Others 24 

27.  A  Composite  Representation  of  Abnormal  Umbilical  Structures,  Based  on  the 

Work  of  Keibel,  Lowy,  and  Others 24 

28.  The  Umbilical  Region  in  a  Fetus  about  Five  Months  Old  Viewed  from  the  Left  .  .     25 

29.  Side  and  Posterior  Views  of  the  Umbilical  Region  in  a  Fetus  of  Six  to  Seven 

Months 25 

30.  Three  Diagrams  of  the  Umbilical  Ring  and  Its  Significance  in  the  Development 

of  Ventral  Hernia 27 

XV 


XVI  LIST    OF    ILLUSTRATIONS 

Fig.  Page 

31.  The  Appearance  of  the  Yolk-sac  (Umbilical  Vesicle)  in  a  Pregnancy,  with  the 

Embryo  5.5  cm.  Long 28 

32.  The  Umbilical  Region,  the  Cord,  and  the  Placenta  at  Term 29 

33.  A  Diagrammatic  Representation  of  the  Umbilical  Region  of  a  Fetus  at  Term  ....  32 

34.  Normal  Umbilicus  according  to  Catteau 35 

35.  A  Type  of  Umbilical  Region  in  the  Adult,  Viewed  from  Within 44 

36.  A  Frequent  Type  of  the  Umbilical  Region  in  the  Adult,  Viewed  from  Within  ....  44 

37.  The  Umbilical  Region  of  an  Adult,  Viewed  from  Within 45 

38.  Classic  Type  of  Umbilicus 47 

39.  Disposition  of  the  Vascular  Cords  (Usual  Type) 48 

40.  Vascular  Cords  of  the  Anastomosing  Type,  Noted  7  Times  in  50  Cases 48 

41.  Vascular  Cord  Type,  Noted  5  Times  in  50  Cases 49 

42.  Vascular  Cords,  Noted  5  Times  in  50  Cases,  Completely  Filling  the  Umbilical 

Ring 49 

43.  Vascular  Cords,  Noted  3  Times  in  50  Cases 49 

44.  Vascular  Cords,  Noted  in  2  out  of  50  Cases 50 

45.  Umbilical  Fascia.     Peritoneum  in  Place 52 

46.  Umbilical  Fascia  and  Umbilical  Mesentery 52 

47.  Reduplication  of  the  Linea  Alba.     Peritoneum  Removed 52 

48.  Atrophy  of  the  Umbilical  Fascia,  Posterior  View 53 

49.  Formation  of  a  Mesentery.     Peritoneum  in  Place 53 

50.  Mesentery  of  the  Urachus  and  of  the  Umbilical  Arteries 53 

51.  Adipose  Fringes.     From  a  Well-developed  Young  Woman.     Peritoneum  in  Place  54 

52.  Adipose  Fringes  in  a  Stout  Subject.     Peritoneum  in  Place 54 

53.  Peritoneal  Diverticula.    Peritoneum  in  Place 55 

54.  Peri-umbilical  Fossettes.     Peritoneum  in  Place 55 

55.  Ovarian  Pedicle  Passing  from  Uterus  out  through  a  Hernial  Ring  in  the  Ab- 

dominal Wall 57 

56.  Extra-abdominal  Multilocular  Fibrocystoma  of  the  Ovary 5S 

57.  An  Extra- abdominal  Multilocular  Fibrocystoma 59 

58.  Superficial  Lymphatics  of  the  Umbilical  Region 64 

59.  The  Deep  Umbilical  Lymphatics  as  Seen  from  the  Peritoneal  Side 65 

60.  The  Umbilical  Vessels  about  the  Time  of  Birth 72 

61.  The  Umbilical  Vessels  in  the  Adult 72 

62.  63.  Method  of  Treating  the  Umbilical  Stump  at  Birth 98 

64.  Nature's  Method  of  Checking  Bleeding  from  the  Umbilical  Arteries 107 

65.  An  Umbilical  Granulation 117 

66.  The  Gradual  Atrophy  of  the  Omphalomesenteric  Duct 121 

67.  An  Umbilical  Polyp  Connected  with  Meckel's  Diverticulum  by  a  Fibrous  Cord  .  .  121 

68.  An  Umbilical  Polyp  Attached  to  the  Small  Bowel  by  a  Fibrous  Cord 121 

69.  An  Umbilical  Polyp  on  the  Prominent  Part  of  an  Umbilical  Hernia :  .  .  123 

70.  A  Polypoid  Outgrowth  from  the  Umbilicus 129 

71.  Tubular  Glands  from  the  Umbilical  Polyp  Shown  in  Fig.  70 129 

72.  A  Diverticular  Tumor  at  the  Umbilicus 132 

73.  A  Glandular  Tumor  from  the  Umbilicus 132 

74.  A  Glandular  Growth  at  the  Umbilicus 133 

75.  Section  in  the  Long  Axis  of  a  Small  Umbilical  Growth 134 

76.  Adenoma  of  the  Umbilicus 135 

77.  Ax  Umbilical  Polyp  Attached  to  a  Meckel's  Diverticulum  by  a  Fibrous  Cord.  138 

78.  Ax  Umbilical  Polyp  Attached  to  a  Meckel's  Diverticulum  by  a  Fibrous  Cord  .  .  .  138 

79.  An  Umbilical  Polyp 139 

80.  A  Small  Intestinal  Polyp  Almost  Fillingthb  Umbilical  Depression 139 

81.  An  Umbilical  Polyp 140 

82.  Portion  of  an  Intestinal  Polyp  Partially  Filling  the  Umbilical  Depression  ....  141 

83.  Transverse  Section  op  a  Pseudopyloric  Congenital  Fistula  at  the  Umbilicus  .  . . .  149 


LIST    OF    ILLUSTRATIONS  XV11 

Fia.  Fage 

84.  High-power  Picture  op  a  Fistulous  Tract  at  the  Umbilicus,  Showing  Glands  Re- 

sembling those  of  the  Pylorus 150 

85.  An  Umbilical  Fistula  Lined  with  Mucosa  Resembling  that  of  the  Stomach 150 

86.  Appearance  of  the  Umbilical  Depression  in  von  Rosthorn's  Case 152 

87.  Gastric  Mucosa  at  the  Umbilicus 153 

88.  Appearance  of  the  Umbilicus  After  Removal  of  the  Stomach  Mucosa  Seen  in 

Fig.  87 154 

89.  Persistence  of  the  Outer  End  of  the  Omphalomesenteric  Duct 156 

90.  Atrophy  of  the  Inner  End  of  the  Omphalomesenteric  Duct 156 

91.  A  Long  Umbilical  Polyp  as  a  Remnant  of  the  Omphalomesenteric  Duct 156 

92.  Meckel's  Diverticulum 159 

93.  A  Meckel's  Diverticulum  Attached  to  the  Abdominal  Wall  at  the  Umbilicus.  .  160 

94.  An  Abnormally  Large  Meckel's  Diverticulum 161 

95.  A  Meckel's  Diverticulum  with  a  Lobulated  Extremity 161 

96.  A  Meckel's  Diverticulum  with  Hernial  Protrusions  from  Its  Surface 162 

97.  A  Short  Meckel's  Diverticulum  Springing  from  the  Mesenteric  Attachment  .  .  163 

98.  An  Accessory  Pancreas  in  the  Tip  of  Meckel's  Diverticulum 163 

99.  A  Meckel's  Diverticulum  Completely  Tying  off  a  Loop  of  Small  Bowel 164 

100.  A  Diverticulum  Tying  Off  a  Loop  of  Small  Bowel 165 

101.  Strangulation  of  a  Meckel's  Diverticulum  Causing  Volvulus  of  the  Ileum.  .  .  .    166 

102.  Fatal  Intestinal  Obstruction  Due  to  the  Passage  of  the  Bowel  through  a 

Hole  in  the  Mesentery  of  a  Meckel's  Diverticulum .170 

103.  Inversion  of  a  Meckel's  Diverticulum  into  the  Lumen  of  the  Bowel 171 

104.  A  Well-developed  Loop  of  Small  Bowel  in  a  Dermoid  Cyst  of  the  Ovary 175 

105.  An  Intestinal  Cyst 176 

106.  An  Intestinal  Cyst  Attached  to  the  Umbilicus  by  a  Pedicle  but  not  Connected 

with  the  Bowel 176 

107.  Volvulus  of  Meckel's  Diverticulum 177 

108.  An  Intestinal  Cyst  Developing  from  Meckel's  Diverticulum 178 

109.  Intestinal  Cysts  in  the  Abdominal  Cavity 182 

1 10.  An  Intramesenteric  Cyst 183 

111.  A  Patent  Omphalomesenteric  Duct 190 

112.  A  Patent  Omphalomesenteric  Duct  with  a  Polypoid  Formation  at  the  Umbilicus  .    190 

113.  A  Very  Short  Omphalomesenteric  Duct 190 

114.  A  Patent  Omphalomesenteric  Duct  with  a  Polyp- like  Formation  at  the  Umbil- 

icus    190 

1 15.  A  Patent  Omphalomesenteric  Duct 192 

116.  A  Patent  Omphalomesenteric  Duct 193 

1 17.  A  Patent  Omphalomesenteric  Duct 197 

118.  A  Patent  Omphalomesenteric  Duct 197 

119.  A  Patent  Omphalomesenteric  Duct 202 

120.  A  Patent  Omphalomesenteric  Duct 205 

121.  A  Patent  Omphalomesenteric  Duct 206 

122.  Part  of  a  Patent  Omphalomesenteric  Duct 206 

123.  Intestinal  Mucosa  Covering  the  Cutaneous  or  Umbilical  End  of  a  Patent  Om- 

phalomesenteric Duct 207 

124.  An  Umbilical  Polyp  and  a  Fibrous  Nodule  at  the  Umbilicus.     There  was  Origin- 

ally a  Patent  Omphalomesenteric  Duct 209 

125.  Longitudinal  Section  through  the  Entire  Center  of  a  Partially  Closed  Om- 

phalomesenteric Duct 209 

126.  A  Patent  Omphalomesenteric  Duct 211 

127.  A  Patent  Omphalomesenteric  Duct  Opening  at  the  Base  of  the  Umbilical  Cord  .  .   216 

128.  A  Patent  Omphalomesenteric  Duct 216 

129.  A  Patent  Omphalomesenteric  Duct  as  Seen  from  the  Abdominal  Cavity 216 

130.  Inversion  of  the  Bowel  through  a  Patent  Omphalomesenteric  Duct  Opening  on 

the  Side  of  the  Umbilical  Cord 219 


XV111  LIST    OF    ILLUSTRATIONS 

Fig.  Page 

131.  A  Patent  Omphalomesenteric  Duct  of  Large  Diameter 224 

132.  Commencing  Prolapsus  of  Small  Bowel  through  a  Patent  Omphalomesenteric 

Duct 224 

133.  Partial  Prolapsus  of  the  Small  Bowel  through  the  Omphalomesenteric  Duct  .  .  .   224 

134.  Prolapsus  of  the  Small  Bowel  through  the  Patent  Omphalomesenteric  Duct  ....   224 

135.  Complete  Prolapsus  of  the  Bowel  through  the  Patent  Omphalomesenteric  Duct   225 

136.  Prolapsus  of  the  Small  Bowel  through  the  Patent  Omphalomesenteric  Duct, 

and  an  Umbilical  Hernia  between  the  Loops  of  Prolapsed  Bowel 225 

137.  Prolapse  of  the  Small  Bowel  through  an  Open  Omphalomesenteric  Duct 227 

138.  Prolapsus  of  the  Bowel  through  a  Patent  Omphalomesenteric  Duct 228 

139.  Prolapsus  of  the  Bowel  through  a  Patent  Omphalomesenteric  Duct,  with  Sec- 

ondary Complications 229 

140.  Prolapsus  and  Inversion  of  the  Intestine  through  a  Patent  Omphalomesenteric 

Duct 230 

141.  Prolapsus  of  the  Bowel  through  the  Patent  Omphalomesenteric  Duct 232 

142.  A  Small  Cyst  of  the  Umbilicus  Due  to  a  Remnant  of  the  Omphalomesenteric 

Duct 238 

143.  Small  Cyst  of  the  Abdominal  Wall  Due  to  a  Remnant  of  the  Omphalomesenteric 

Duct 238 

144.  A  Small  Intestinal  Cyst  Lying  between  the  Peritoneum  and  the  Recti 240 

145.  An  Omphalomesenteric  Duct  Originating  from  the  Concave  Side  of  the  Bowel 

and  Attached  to  the  Umbilicus  by  a  Fibrous  Cord 243 

146.  A  Remnant  of  an  Omphalomesenteric  Duct  Causing  Fatal  Intestinal  Obstruc- 

tion    245 

147.  A  Small  Umbilical  Concretion 249 

148.  Acute  Inflammation  of  the  Umbilicus  Due  to  an  Accumulation  of  Sebaceous 

Material 249 

149.  Cholesteatoma  from  the  Umbilicus  in  Case  1 251 

150.  Cholesteatoma  from  Case  2 251 

151.  A  Connective-tissue  Projection  Really  Representing  a  Small  Fibroma  in  the 

Floor  of  the  Umbilicus 252 

152.  Enlargement  of  Fig.  151 252 

153.  Subumbilical  Phlegmon 262 

154.  The  Subumbilical  Space 264 

155.  Paget's  Disease  of  the  Umbilicus 270 

156.  Paget's  Disease  of  the  U/mbilicus 270 

157.  Paget's  Disease  of  the  Umbilicus 271 

158.  Paget's  Disease  of  the  Umbilicus 274 

159.  The  Appearance  in  a  Case  of  Paget's  Disease  of  the  Umbilicus  After  Treatment 

with  Radium 275 

160.  Syphilis  of  the  Umbilicus 284 

161.  Atrophic  Tuberculid  Starting  at  the  Umbilicus 286 

162.  Leakage  from  an  Abdominal  Aneurysm   Producing  a  Temporary  Abdominal 

Tumor;  Subsequent  Escape  of  the  Blood  into  the  Right  Renal  Pocket 288 

163.  The  Manner  in  Which  a  Periprostatic  Abscess  may  Occasionally  Rupture  at 

the  Umbilicus 289 

164.  Escape  of  Pleural  Fluid  from  the  Umbilicus 289 

165.  The  Opening  of  a  Broad  Ligament  Abscess  at  the  Umbilicus 290 

166.  Abdominal  Pregnancy  with  Spontaneous  Escape  of  Liquor  Amnii  from  the  Um- 

bilicus     348 

167.  Small  Papilloma  in  the  Umbilical  Depression 365 

168.  A  Shall  Umbilical  Tumor  Containing  Glands  and  Stroma  Identical  with  Those 

of  the  Uterine  Mucosa 376 

169.  Glands  from  a  Small  U\iisiLirALTuMOR 377 

170.  Typical  Uterine  Mucosa  in  a  Small  Umbilical  Tumor.     An  Enlargement  of  Area 

B  in  Fig.  168 378 


LIST    OF    ILLUSTRATIONS  xix 

Fig.  Page 

171.  Glands  in  a  Small  Umbilical  Tumor 379 

172.  Dilated  Glands  in  a  Small  Umbilical  Tumor 380 

173.  Dichotomous  Branching  of  Glands  in  a  Small  Umbilical  Tumor 381 

174.  Uterine  Glands  in  an  Umbilical  Tumor 381 

175.  Gland  Hypertrophy  in  a  Small  Umbilical  Tumor 382 

176.  A  Tumor  of  the  Umbilicus  Composed  Partly  of  Hypertrophic  Sweat-glands 383 

177.  Uterine  Mucosa  in  an  Umbilical  Tumor 384 

178.  A  Small  Umbilical  Tumor  Containing  Numerous  Glands 388 

179.  Glands  in  a  Small  Umbilical  Tumor 389 

180.  An  Adenomyoma  in  the  Abdominal  Wall  Near  the  Anterior  Iliac  Spine 394 

181.  A  Small  Umbilical  Tumor  Containing  Glands  Similar  to  Those  of  the  Body  of  the 

Uterus 396 

182.  Adenomyoma  of  the  Umbilicus 397 

183.  A  Group  of  Sweat-glands  in  an  Umbilical  Tumor 398 

184.  Appearance  of  the  Carcinomatous  Umbilicus  After  Removal 424 

185.  Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma  of  the  Ovaries 432 

186.  A  Malignant  Growth  of  the  Umbilicus,  Apparently  a  Carcinoma  Secondary  to 

Some  Abdominal  Growth 439 

187.  Adenocarcinoma  of  the  Umbilicus  Secondary  to  an  Intra-abdominal  Growth  ....   440 

188.  Adenocarcinoma  of  the  Umbilicus 441 

189.  A  Section  Showing  Carcinoma  of  the  Right  Inguinal  Glands 442 

190.  Secondary  Carcinoma  of  the  Umbilicus 443 

191.  Telangiectatic  Myxosarcoma  of  the  Umbilicus 450 

192.  Appearance  of  the  Umbilicus  After  Removal  of  the  Tumor  Shown  in  Fig.  191. .  450 

193.  Myxosarcoma  of  the  Umbilicus 451 

194.  Telangiectatic  Myxosarcoma  Projecting  from  the  Right  Side  of  the  Umbilicus  .  .   452 

195.  A  Telangiectatic  Myxosarcoma 452 

196.  A  Case  of  Congenital  Umbilical  Hernia 460 

197.  An  Amniotic  Hernia 462 

198.  Several  Loops  of  Bowel  Which  Lay  Outside  the  Umbilicus  and  were  Nipped  Off 

During  Fetal  Life.     The  Child  Lived  a  Short  Time  After  Birth 464 

199.  A  Serous  Umbilical  Hernia 469 

200.  Freeing  the  Umbilical  Hernial  Sac  from  the  Abdomen 472 

201.  Closure  of  the  Hernial  Opening  at  the  Umbilicus 473 

202.  Closure  of  the  Hernial  Opening  at  the  Umbilicus 474 

203.  An  Umbilical  Hernia  Associated  with  Marked  Prolapsus  of  the  Abdominal  Wall  475 

204.  An  Umbilical  Hernia  and  a  Markedly  Pendulous  Abdomen  in  a  Patient  Weigh- 

ing 464  Pounds 476 

205.  The  Abdominal  Scar  After  the  Removal  of  a  Very  Large  Area  of  Fat 477 

206.  An  Umbilical  Cyst 478 

207.  Exstrophy  of  the  Bladder  Opening  at  or  Near  the  Umbilicus 482 

208.  Exstrophy  of  the  Bladder.     A  side  View  of  the  Case  Depicted  in  Fig.  207,  Show- 

ing the  Relative  Distance  from  the  Symphysis  to  the  Opening  in  the  Abdominal 
Wall : 483 

209.  Exstrophy  of  the  Bladder 483 

210.  Escape  of  Urine  from  the  Umbilicus  When  the  Inner  Urethral  Orifice  Is 

Blocked  by  a  Membrane 488 

211.  A  Patent  Urachus  with  a  Mushroom-like  Projection  at  the  Umbilicus 489 

212.  A  Patent  Urachus  with  a  Penile  Projection  at  the  Umbilicus 489 

213.  The  Appearance  of  the  Umbilicus  in  a  Case  in  Which  both  a  Patent  Omphalomes- 

enteric Duct  and  a  Patent  Urachus  Existed 493 

214.  Cross-section  of  the  Patent  Omphalomesenteric  Duct  and  of  the  Patent  Ura- 

chus in  the  Same  Child 493 

215.  A  Picture  of  the  Child  Three  Weeks  After  Removal  of  a  Patent  Omphalomes- 

enteric Duct  and  a  Patulous  Urachus 494 

216.  A  Patent  Urachus 497 


XX  LIST    OF    ILLUSTRATIONS 

Fig.  Paqb 

217.  A  Urachus  Open  from  Bladder  to  Umbilicus 498 

218.  An  Open  Urachus 499 

219.  Escape  of  Urine  from  the  Umbilicus  Due  to  a  Patent  Urachus 502 

220.  A  Patent  Urachus  with  a  Penile  Projection  at  the  Umbilicus 505 

221.  A  Ring-shaped  Vesical  Calculus  with  a  Fine  Hair  in  Its  Axis 507 

222.  A  Partially  Patent  Urachus 515 

223.  A  Patent  Urachus 517 

224.  A  Portion  of  a  Urachus  Seven  Times  Enlarged,  with  Numerous  Large  and  Small 

Dilatations 518 

225.  Portion  of  a  Urachus  Ten  Times  Enlarged 518 

226.  Cysts  of  the  Urachus  Arranged  Like  a  String  of  Pearls .- 520 

227.  Spindle-Shaped  Dilatations  of  the  Urachus 520 

228.  A  Small  Cyst  of  the  Urachus 532 

229.  A  Patent  Urachus 534 

230.  A  Multilocular  Cyst  of  the  Urachus 535 

231.  Section  of  a  Patent  Urachus .' 536 

232.  Transverse  Section  of  a  Patent  Urachus 537 

233.  A  Small  Cyst  of  the  Urachus 538 

234.  A  Diffuse  Neuroma  of  the  Bladder 542 

235.  Cut  Surface  of  the  Bladder  Showing  a  Diffuse  Neuroma  of  Its  Walls 543 

236.  A  Diffuse  Neuroma  Forming  a  Mantle  Around  the  Cavity  of  the  Bladder 544 

237.  Diagram  Showing  the  Arrested  Development  of  the  Genital  Tract  and  the  Re- 

lation of  the  Malformed  Parts  to  the  Cyst  of  the  Urachus 551 

238.  Section  of  the  Segment  of  Urachus  Which  Passed  between  the  Bladder  and  the 

Cyst- wall,  as  Seen  under  a  Low  Power 552 

239.  The  Abdominal  Contour  in  a  Case  of  Very  Large  Urachal  Cyst 558 

240.  A  Urachal  Cyst  Turned  Inside  Out  and  Showing  Papillary  Masses,  Particularly 

in  the  Lower  Part  of  the  Picture 559 

241.  Infected  Urachal  Remains 568 

242.  An  Infected  Urachus  Opening  between  the  Umbilicus  and  Bladder 570 

243.  Urachal  Cyst 576 

244.  A  Dilated  Urachus  Communicating  with  the  Bladder 579 

245.  Large  Accumulation  of  Urine  in  a  Partially  Patent  Urachus 579 

246.  An  Infected  Urachus  Opening  at  the  Umbilicus 580 

247.  A  Patent  Urachus  Dilated  in  Its  Middle  Portion 580 

248.  Accumulation  of  a  Large  Quantity  of  Urine  in  a  Urachal  Pouch 581 

249.  Fetal  Bones  Removed  from  an  Old  Extra-uterine  Pregnancy  Sac 584 

250.  A  Phosphatic  Deposit  on  the  End  of  a  Long  Bone 585 

251.  A  Dilated  Urachus  Communicating  with  the  Bladder 598 

252.  Urachal  Cyst 599 

253.  Urachal  Cyst 603 

254.  Urachal  Cyst 603 

255.  A  Patent  Urachus  Containing  a  Vesical  Calculus 625 

256.  Carcinoma  of  the  Patent  Urachus 632 

257.  A  Multilocular  and  Malignant  Cyst  of  the  Urachus 637 

258.  Giant-cells  in  the  Wall  of  an  Adenocarcinomatous  Cyst  of  the  Urachus 638 

259.  Giant-cells  in  the  Wall  of  an  Adenocarcinoma  of  the  Urachus 639 

260.  Giant-cells  in  the  Wall  of  an  Adenocarcinomatous  Cyst  of  the  Urachus.  .  .640-641 

261.  Adenocarcinoma  of  the  Urachus 642 

262.  A  Papillary-like  Area  i.\  an  Adkxocarcinomatous  Cystofthe  Urachus 643 

263.  Metastasis  from  Adenocarcinoma  of  the  Urachus 644 

264.  An  Umbilical  Cyst 645 

265.  \\  aj.i  of  an  Umbilical  Cyst 645 

266.  Giant-cells  in  the  Wall  of  an  Umbilical  Cyst 646 

267.  Tuberculosis  of  the  Urachus 652 

268.  An  Area  Suggesting  a  Tubercle 653 

269.  A  Tubercle  from  Dr.  Eastman's  Case  of  Tuberculosis  of  the  Urachus 654 


LIST  OF  PLATES 

Plate  Page 

I.  Drawings  of  Normal  Umbilici 40 

II.  Drawings  of  Normal  Umbilici 41 

III.  Drawings  of  Normal  Umbilici 42 

IV.  Drawings  of  Normal  Umbilici 43 

V.  Cancer  of  the  Umbilicus  Apparently  Secondary  to  a  Tumor  of  the  Ovary.  .434-435 

VI.  Umbilical  Hernia 466-467 

VII.  Exstrophy  of  the  Bladder 484-485 


xxi 


THE  UMBILICUS  AND  ITS  DISEASES. 

CHAPTER  I. 
EMBRYOLOGY  OF  THE  UMBILICAL  REGION. 

General  considerations. 
Development  of  the 

Amnion. 

Yolk-sac. 

Body-stalk. 

Allantois  and  Urachus. 

Ccelom. 

Umbilical  vessels. 

Umbilical  cord. 

Omphalomesenteric  duct. 

A  compeehensive  study  of  the  diseases  of  the  umbilicus  necessarily  calls  for  a 
thorough  knowledge  of  the  embryology  of  this  region.  In  early  fetal  life,  however, 
the  changes  are  so  rapid  and  varied  that  they  might  well  be  termed  kaleidoscopic ; 
hence  it  becomes  somewhat  difficult  to  follow  the  various  steps  in  the  development 
of  the  umbilicus.* 

Among  the  various  authors  who  have  discussed  the  diseases  of  the  urachus  and 
who  have  dwelt  briefly  upon  its  development  may  be  mentioned  Cazin  (1862), 
Ahlfeld  (1876),  Freer  (1887),  Ledderhose  (1890),  Monod  (1899),  and  Vaughan 
(1905).  The  literature  on  the  embryology  of  the  umbilicus  is,  however,  on  the 
whole  very  meager. 

In  order  that  the  gradual  development  of  the  umbilicus  may  be  clearly  under- 
stood, it  is  necessary  to  begin  with  a  very  young  embryo.  Fig.  1  represents  an  em- 
bryo 0.7  mm.  long.  The  embryo  forms  only  a  very  small  portion  of  the  specimen. 
On  its  dorsal  surface,  and  forming  a  sort  of  cap,  is  the  amnion  (colored  green). 
The  yolk-sac  is  relatively  large,  and  lies  in  front  of  the  embryo.  Connecting 
all  the  fetal  structures  with  the  placenta  is  the  body-stalk.  It  will  be  noted 
even  at  this  stage  that  a  portion  of  the  yolk-sac  is  projecting  into  the  body-stalk. 
This  is  the  commencement  of  the  allantois,  which  is  in  reality  a  recess  of  the 
yolk-sac. 

When  the  embryo  is  about  1.7  mm.  long  (Fig.  2),  its  outlines  are  well  defined 
and  the  heart  is  clearly  seen.  The  amniotic  cavity  is  much  larger,  and  the  amnion, 
both  above  and  below,  extends  farther  forward  than  the  embryo.  The  yolk-sac, 
although  larger,  has  not  kept  pace  in  growth  with  the  embryo  and  the  amnion. 
It  is  continued  upward  in  the  embryo,  forming  the  fore-gut,  and  downward,  form- 
ing the  hind-gut.  The  allantois  has  projected  farther  into  the  body-stalk.  At  this 
period  a  depression  exists  where  the  amnion  and  yolk-sac  join;  this  marks  the  in- 

*  The  illustrations  in  this  chapter  are  arranged  chiefly  according  to  the  age  of  the  embiyo 
from  which  they  were  obtained. 

2  1 


THE    UMBILICUS   AND    ITS    DISEASES. 


Fig.  1. — Sagittal  Section  Showing  a  Very  Early  Stage  in  the  Formation  of  the  Umbilicus  and  Allantois. 

(Human  embryo,  0.7  mm.  long.) 
Note  the  origin  of  the  allantois  from  the  cavity  of  the  yolk-sac.     The  umbilical  region  will  be  formed  by  a  gradua 
approximation  of  the  cranial  and  caudal  ends  of  the  yolk-sac,  as  indicated  by  the  arrows.     The  embryonic  surface  of 
the  yolk-sac  will  later  become  the  alimentary  canal. 


Fj>;.  2. — A  More  Advanced  Stage  in  the  Formation  of  the  Umbilical  Region.      (Human  embryo,  1.7  mm.  long. 

-Mall  series,  391.)      (This  embryo  has  been  very  carefully  described  by  Dr.  Walter  E.  Dandy  (Amer.  Jour.  Anat., 

1910,  x,  85). 

Note  the  advancing  approach  of  the  cranial  and  caudal  portions  of  the  yolk-sac  and  its  division  into  a  main 
cavity  and  two  recesses,  the  fore-gut  and  the  hind-gut,  into  the  latter  of  which  the  allantois  now  opens.  The 
vitelline  arteries  and  veins  are  clearly  seen  on  the  embryonic  side  of  the  yolk-sac.  The  amnion  is  now  gradually 
enveloping  the  embryo.  Compare  the  situation  of  the  coelom  in  this  with  that  in  the  subsequent  pictures.  There  is 
a.-,  yet  no  umbilical  cord.      For  the  first  stage  of  its  development,  Bee  Kin.  3. 


EMBRYOLOGY    OF    THE    UMBILICAL   REGION. 


3 


folding  of  the   e  x  o  c  oe  1  o  m  .     The  arrows  indicate  the  direction  that  it  will  fol- 
low later. 

In  Fig.  3  we  have  a  composite  picture  representing  the  appearances  in  an 
embryo  2.5  mm.  long.  The  embryo  has  now  assumed  a  definite  form,  and  many  of 
its  structures  can  be  traced.  The  amnion  has  continued  to  grow  and  now  almost 
completely  encircles  the  embryo.     The  yolk-sac  has  increased  little,  if  any,  in  size. 


Fig.  3. — A  Composite  Picture  Showing  the  Formation-  of  the  Umbilicus  in  an  Embryo  2.5  mm.  Long. 
This  drawing  was  made  after  a  careful  study  of  several  embryos  of  this  length  described  in  the  literature.  Each 
author  was  interested  in  some  particular  region,  but  not  in  the  embryo  as  a  whole.  The  yolk-sac  has  now  become 
greatly  narrowed  at  its  entrance  into  the  body.  The  narrowed  portion  is  now  referred  to  as  the  vitelline  or  omphalo- 
mesenteric duct.  In  its  wall  are  seen  the  right  omphalomesenteric  vessels.  The  digestive  tract  already  shows  well- 
defined  differentiation.  The  allantois  now  opens  into  the  cloaca.  The  amnion  almost  completely  encircles  the  embryo, 
and  in  so  doing  has  combined  the  vitelline  duct  'with  the  body-stalk,  containing  the  chorionic  vessels  and  the  allantois, 
into  a  common  cord.  As  the  development  advances  this  cord  will  become  more  compact,  thinner,  and  longer.  The 
exoccelom  has  been  drawn  into  the  embryo  and  will  later  unite  with  the  ccelom  of  the  pleuroperitoneal  cavity. 


It  has  been  forced  away  from  the  embryo  by  the  increase  in  development  of  the 
embryo  and  of  the  amnion.  The  narrowed  portion  of  the  yolk-sac  is  now  called 
the  omphalomesenteric  or  vitelline  duct.  This  duct  natur- 
ally communicates  with  the  digestive  tract,  which  is  now  becoming  more  and 
more  differentiated.     The  digestive  tract  ends  below  in  the   cloaca. 

We  can  now  for  the  first  time  really  speak  of  an  umbilical  cord.     This  consists 
of  the  body-stalk  and  the  omphalomesenteric  duct,  which  have  as  yet  not  fused. 


4  THE    UMBILICUS    AND    ITS    DISEASES. 

The  portion  of  the  yolk-sac  now  forming  the  cloaca  has  been  carried  far  back, 
and  opening  into  it  is  the  allantois,  which  can  be  followed  out  in  the  body-stalk 
almost  to  the  placenta.  It  terminates  in  a  bulbous  extremity.  Its  caliber  in  the 
cord  may  vary  considerably. 

At  this  stage  the  exoccelom  has  been  carried  in  between  the  amnion  and  the 
yolk-sac.  It  fills  in  the  space  around  the  omphalomesenteric  duct,  and  is  destined 
to  join  the  pleuroperitoneal  cavity. 


Fig.  4. — A  Diagrammatic  Representation  of  a  Human-  Embryo,  about  3.5  mm.  Long,  Showing  the  Effect  of  the 
Expanding  Amnion  upon  the  Yolk-sac  and  Body-stalk. 
The  amnion  has  now  completely  encircled  the  embryo,  and  with  its  increase  in  size  has  crowded  the  yolk-sac 
away.  Outside  the  amnion  the  yolk-sac  and  body-stalk  are  separate  structures;  inside  the  amniotic  ring  they  are  fused, 
forming  the  umbilical  cord.  The  amnion  covers  the  cord  as  far  as  the  embryo.  It  is  probable  that  the  tension  pro- 
duced on  the  yolk-Stalk  by  the  amnion  contributes  to  the  primitive  kink  in  the  alimentary  canal. 


In  Fig.  4  we  have  a  diagrammatic  representation  of  a  human  embryo  3.5  mm. 
long.  The  embryo  is  completely  encircled  by  the  amnion.  The  yolk-sac  is  some- 
what larger  than  before,  but  is  smaller  than  the  fetal  sac.  The  umbilical  cord  is 
formed  of  the  body-stalk  and  omphalomesenteric  duct.  Externally  to  the  amnion 
they  are  separate  and  distinct;  within  the  cavity  they  are  held  together  by  a  sheath 
consisting  of  amnion. 

Fig.  5  represents  a  human  embryo  5  mm.  in  length.     The  amnion  is  now  much 


EMBRYOLOGY    OF    THE    UMBILICAL   REGION.  5 

larger  than  the  yolk-sac,  and  the  portion  of  the  omphalomesenteric  duct  external 
to  the  sac  has  become  much  smaller  than  the  body-stalk.  The  esophagus,  stomach, 
liver,  pancreatic  buds,  and  first  curve  of  the  small  intestine  are  clearly  visible. 
Attached  to  this,  and  extending  out  into  the  cord,  is  the  omphalomesenteric  or 
vitelline  duct,   accompanied  by  the  omphalomesenteric  vessels.     The  allantois, 


Fig.  5. — Sagittal  View  of  a  Human  Embryo  5  mm.  in  Length. 
In  large  part  the  left  halves  of  the  amnion  and  embryo  have  been  removed,  in  order  to  bring  clearly  into  view 
the  structure  of  the  cord.  The  expanding  amnion  has  almost  reached  the  chorion,  hence  but  little  remains  of  the 
extra-amniotic  portion  of  the  yolk-stalk  and  of  the  body-stalk.  The  umbilical  cord  has  become  longer.  The  caudal 
portion  of  the  cord  is  firm  and  contains  the  umbilical  arteries  and  veins;  the  latter,  soon  pfter  leaving  the  body,  form 
a  common  trunk,  which  usually  curves  toward  the  left.  Between  the  two  umbilical  arteries  lies  the  allantois,  the 
bulbous  end  of  which  still  persists  almost  to  the  amnion.  The  cranial  portion  of  the  cord  is  looser  in  texture.  It 
contains  the  ccelomic  cavity,  in  which  lies  the  omphalomesenteric  duct,  accompanied  by  its  vessels.  Note  that  the 
superior  mesenteric  vein  empties  into  the  omphalomesenteric  vein  behind  the  pancreatic  buds.  The  omphalomesenteric 
artery  still  arises  by  several  branches  from  the  aorta. 


which  opens  into  the  cloaca,  can  be  followed  outward  in  the  cord  almost  to  the 
placenta.  The  cord  now  contains  the  omphalomesenteric  duct  and  its  vessels, 
surrounded  by  exoccelom,  as  well  as  the  two  umbilical  arteries,  the  umbilical  vein, 
and  the  allantois.  By  the  time  the  embryo  is  10  mm.  long  (Fig.  8)  the  yolk-sac  is 
relatively  very  small,  the  cord  is  well  formed,  and  in  its  outer  portion  already  shows 


6 


THE    UMBILICUS   AND    ITS    DISEASES. 


some  tendency  to  twist.  The  small  intestine  still  consists  of  one  loop,  and  the 
greater  portion  of  it  has  been  drawn  out  into  the  cord  apparently  by  the  omphalo- 
mesenteric duct  or  its  vessels.  It  lies  in  a  cavity — the  exoccelom.  The 
umbilical  cord,  on  section  near  the  fetus,  is  now  seen  to  contain  the  umbilical  vein, 
the  exoccelomic  cavity  with  the  major  part  of  the  small  intestine  and  the  omphalo- 
mesenteric vessels  lying  in  it;  in  the  lower  wall  of  the  cord  the  umbilical  arteries 
appear  with  the  allantois  between  them. 


Esophagus 


R.gtit  umbilical  vein.' 
which  Later  di'sappea' 


Forward  shifting  of 
muscles  of  body  wall 
changing 


Position    of   left  umbilical 
hid.  .s.  carried  to  its  , 


Ult.mate   position  in 
tnidplane    of  body. 


Fig.  6. — Anterior  View  and  Transverse  Section  of  a  Human  Embryo  7  mm.  Long,  Showing  the  Umbilical 

Region. 

The  umbilical  cord  has  been  cut  off  near  the  embryo  in  order  to  show  the  thick  lower  portion  containing  the 
umbilical  vessels  and  allantois.  The  upper  portion  consists  mainly  of  the  exoccelomic  cavity,  which  contains  the 
intestinal  loop  and  the  omphalomesenteric  vessels.  The  omphalomesenteric  duct  has  been  drawn  to  the  right,  in 
order  that  it  may  be  more  clearly  seen.  Note  the  narrow  ccelomic  ring  through  which  the  intestine  and  vessels 
emerge.     At  the  outer  end  of  the  intestinal  loop  the  omphalomesenteric  duct  begins. 

The  lower  diagram  represents  a  transverse  section  of  the  body  at  the  level  indicated  in  the  upper  picture.  The 
purpose  of  this  diagram  is  to  show  the  shifting  of  the  left  umbilical  vein  toward  the  mid-line  of  the  body,  as  a  result  of 
the  ventral  growth  of  the  body-wall.     The  right  umbilical  vein  is  destined  to  disappear. 


By  the  time  the  embryo  has  reached  18  mm.  in  length  (Fig.  10)  the  small  in- 
testine shows  numerous  convolutions,  and  nearly  all  the  small  bowel  lies  in  the 
exoccelomic  cavity  in  the  cord  outside  of  the  embryo. 

In  a  longitudinal  section  of  the  cord  near  the  body,  in  an  embryo  23  mm.  in 
length  (Fig.  11),  the  exoccelomic  cavity  is  seen  to  contain  convolutions  of  small 
bowel,  having  attached  to  them  the  omphalomesenteric  vessels.  In  the  lower 
wall  of  the  cord  are  the  umbilical  arteries,  the  umbilical  vein,  and  the  allantois. 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION.  , 

The  small,  cyst-like  spaces  in  the  wall  of  the  cord  are  partially  organized  areas  of 
exoccelom. 

By  the  time  the  embryo  is  3  cm.  long  the  exoccelomic  cavity  in  the  cord  contains 
many  loops  of  small  bowel  (Fig.  12). 

With  the  growth  of  the  embryo  the  intestines  rapidly  recede  into  the  abdomen 
(Fig.  15).  The  exoccelom  and  all  traces  of  the  omphalomesenteric  duct  and  its 
vessels  disappear,  but  remnants  of  the  allantois  may  or  may  not  persist  in  the  cord. 

After  this  short  survey  of  the  gradual  development  of  the  umbilical  region  of  the 
embrvo  it  mav  be  well  to  trace  brieflv  the  individual  structures. 


Proximal  bulbous  end  of 
omph.  mes.  duct  in  urnb. cord' 


nes.  artery  and  >ei« 


Exo-coelo 


Fig.  7. — Sagittal  Section  of  the  Umbilical  Region  in  an  Embryo  7  mm.  in  Length. 
This  is  a  reconstruction  from  the  Mall  embryo  No.  2.  A  detailed  description  of  this  embryo  by  Mall  will  be  found 
in  the  Journal  of  Morphology,  1S91,  vol.  v,  p.  459.  The  exoccelom  in  the  cord  contains  the  omphalomesenteric  stalk, 
in  the  body  of  which  are  seen  the  omphalomesenteric  vessels  and  the  duct.  The  connection  of  the  duct  with  the 
intestine  has  disappeared,  but  the  duct  still  persists  in  the  cord  and  shows  a  bulbous  dilatation  at  its  proximal  end. 
If  it  still  persists  in  later  life,  we  shall  have  a  cyst  in  the  abdominal  wall  or  in  the  structures  of  the  umbilicus.  The 
junction  of  the  superior  mesenteric  vein  with  the  omphalomesenteric  vein  is  clearly  seen  in  the  mesentery. 


THE  AMNION. 

A  clear  idea  of  the  way  in  which  the  amnion  develops  is  essential,  inasmuch  as 
this  membrane  plays  an  important  role  in  the  formation  of  the  umbilical  cord,  and 
occasionally  of  the  umbilical  region  itself.  In  the  very  early  embryo  (Fig.  1)  it  is  a 
small,  flaccid  sac,  covering  the  posterior  surface  of  the  embryo. 

By  the  time  the  embryo  reaches  1.7  mm.  in  length  (Fig.  2),  the  amnion  has  in- 
creased in  size  to  such  an  extent  that  it  not  only  covers  the  posterior  surface  of  the 
embryo,  but  has  also  extended  beyond  the  head  and  tail,  and  already  shows  a 
tendency  to  arch  over  the  anterior  surface. 

When  the  embryo  reaches  2.5  mm.  in  length,  the  amnion  is  seen  to  have  almost 
engulfed  the  embryo,  surrounding  it  on  all  sides  except  where  the  yolk-sac  and  body- 
stalk  enter  its  ventral  surface.  Fig.  3  clearly  indicates  that  the  expansile  force  of 
the  amnion  and  of  the  embryo  has  pushed  the  major  portion  of  the  yolk-sac  away. 


8 


THE    UMBILICUS    AND    ITS    DISEASES. 


leaving  only  its  narrowed  portion — now  called  the  omphalomesenteric  duct — to 
connect  it  with  the  digestive  tract. 

Fig.  4  shows  the  amniotic  sac  of  an  embryo  3.5  mm.  long.  Here  the  fetus  and 
the  major  portion  of  the  omphalomesenteric  duct  and  of  the  body-stalk  are  con- 
tained in  the  amniotic  cavity,  which  is  approximately  spherical. 

By  the  time  the  embryo  is  5  mm.  in  length  the  amniotic  sac  is  much  larger  than 


10  mm<  "fi 


Fig.  8. — Sagittal  View  of  the  Umbilical  Region  of  a  Human  Embryo  10  mm.  in  Length. 
The  yolk-sac  now  lies  far  removed  from  the  umbilical  cord;  its  vessels  and  stalk  follow  a  tortuous  course.  The 
umbilical  cord  here  shows  the  first  indication  of  a  twist,  which  may  be  caused  by  the  embryo  rotating  toward  the  right. 
In  the  embryos  examined  by  us  there  has  been  but  one  exception  to  this  rule.  The  small  intestine  extends  a 
considerable  distance  into  the  exoeoelom  of  the  cord.  At  the  outer  end  of  the  intestinal  loop  is  situated  the  delicate 
omphalomesenteric  duct.  The  omphalomesenteric  vein  passes  on  the  left  side  of  the  intestinal  loop;  the  artery,  on  the 
right  side. 


the  yolk-sac  (Fig.  5),  and  the  amnion  is  reflected  in  on  the  cord  to  the  umbilicus. 
In  rare  instances,  as  noted  on  page  67,  when  the  skin  is  lacking  at  the  umbilicus, 
the  amnion  covers  over  this  defect,  forming  an   amnion   umbilicus. 

When  the  embryo  reaches  10  mm.  in  length,  the  amnion  is  well  developed  (Fig. 
8).  The  amnion  of  an  embryo  23  mm.  long  (Fig.  11)  presents  essentially  the  same 
picture. 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


Coelo 


n-oximai  mtes 


mb  vein 
Left  umb.arter-y 


Distal  end  of  allantois 


Fig.  9. — Graphic  Reconstruction  of  the  Umbilical  Cord  of  a  Human  Embryo  12.5  mm.  in  Length.     (Mall 

collection,  No.  317.) 

The  figure  to  the  left  shows  the  manner  in  which  the  cord  has  been  cut  into  the  portions  I,  II,  and  III.  On  the 
right  are  shown  frontal  views  of  the  three  sections.  They  are  represented  as  being  seniitransparent,  in  order  to  give 
a  clear  idea  of  the  course  of  the  contained  structures. 

Section  I:  Embryonic  end  of  cord,  showing  ccelomic  ring  through  which  protrudes  the  primitive  intestine.  Note 
the  position  of  the  proximal  intestine  (jejunum)  and  the  distal  intestine  (ileum).  To  the  right  and  above,  the 
omphalomesenteric  vessels  are  seen  emerging  by  the  side  of  the  intestine.  The  vein  comes  from  above  the  gut  and 
the  artery  from  below;  between  them  lies  the  duct,  which  is  still  connected  with  the  intestine.  A  delicate  mesente- 
riolum  accompanies  these  structures  for  a  short  distance  into  the  cord  (cf.  also  Fig.  7).  The  umbilical  arteries  and 
vein  are  seen  in  the  lower  part  of  the  cord.     Here  the  allantois  lies  between  the  arteries  and  becomes  obliterated. 

Section  II:  This  section  of  the  cord  is  farther  from  the  umbilicus,  and  shows  a  twist  of  the  structures,  somewhat 
after  the  manner  of  the  left  turn  of  a  screw.  The  exoccelom  with  its  contents  now  lies  to  the  right ;  the  umbilical  vessels 
and  allantois  have  shifted  to  the  left.  The  allantois  has  again  increased  in  size,  and  lies  between  the  umbilical  arteries 
and  the  exoccelom. 

Section  III:  This  section  of  the  cord  is  still  farther  from  the  umbilicus.  It  shows  the  amniotic  ring,  through  which 
emerge  the  omphalomesenteric  duct  and  its  vessels.  The  allantois  decreases  rapidly  in  size  and  becomes  lost  between 
the  left  umbilical  artery  and  the  umbilical  vein. 


10 


THE    UMBILICUS    AND    ITS    DISEASES. 


THE  YOLK-SAC. 

In  an  early  pregnancy,  when  the  embryo  is  about  0.7  mm.  long  (Fig.  1),  the 
yolk-sac  is  represented  by  a  nearly  circular  cyst,  intimately  blended  with  the  ante- 
rior surface  of  the  embryo.  The  sac  has  relatively  thin  walls,  which  are  traversed 
by  delicate  traceries  of  blood-vessels.  Even  in  this  early  stage  a  small  prolongation 
of  the  yolk-sac  extends  into  the  body-stalk.  This  prolongation  is  the  beginning  of 
the  allantois. 


Allautois 
Uinb.  vein 


limb,  arteries 


Qmph.mes.  vessels 
in  exo-coelorn 


Fig.  10. — Anterior  View  of  the  Umbilical  Cord  of  a  Human  Embryo  18  mm.  in  Length. 
A  portion  of  the  cord  has  been  removed,  as  shown  by  the  dotted  line.  The  exoccelomic  cavity  has  increased  mater- 
ially in  size  and  contains  several  loops  of  intestine,  including  the  cecum  and  budding  appendix,  seen  on  the  extreme 
left  (right  in  picture).  The  narrow  ccelomic  ring  is  obscured  by  the  intestine.  The  omphalomesenteric  duct  has  dis- 
appeared, and  we  now  have  only  the  omphalomesenteric  vessels  passing  out  into  the  exoccelom.  This  more  rapid 
disappearance  of  the  delicate  epithelial  structure  of  the  vitelline  duct,  as  contrasted  with  the  preservation  of  the 
stronger  tissues  of  the  blood-vessels,  is  probably  caused  by  the  continued  tension  to  which  the  yolk-stalk  is  subjected. 
(See  Figs.  11  and  12  )  The  exoccelomic  cavity  rapidly  tapers  to  a  narrow  chink,  as  seen  in  the  upper  and  more  distal 
section.  In  the  mid-line  of  the  cord  below  are  the  two  umbilical  arteries,  with  the  allantois  between  and  slightly 
below  them.  The  umbilical  vein  lies  to  the  left.  The  characteristic  twist  of  the  cord,  including  all  of  its  structures, 
is  clearly  seen. 


When  the  embryo  has  reached  a  length  of  about  1.7  mm.  (Fig.  2),  the  yolk-sac 
is  larger,  but  has  not  kept  pace  in  development  with  either  the  embryo  or  the 
amnion.  It  has  extended*  into  the  anterior  surface  of  the  embryo,  above  forming 
the  fore-gut,  below  the  hind-gut.  The  allantois,  which  has  originated  from  the 
yolk-sac  and  is  still  connected  with  it,  extends  much  farther  into  the  body-stalk. 

*  In  reality  it  is  the  forward  growth  of  the  upper  and  lower  ends  of  the  embryo,  as  indicated 
by  the  arrows,  that  produces  the  recesses  destined  to  become  the  alimentary  canal. 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


11 


By  the  time  the  embryo  is  2.5  mm.  in  length  (Fig.  3)  the  yolk-sac  is  smaller 
than  either  the  embryo  or  the  amnion.  With  the  increase  in  size  of  the  amniotic 
sac  the  yolk-sac  has  been  forced  away  from  the  embryo.  The  cavity  of  the  yolk- 
sac,  however,  still  communicates  freely  with  the  digestive  tract  by  a  broad  channel — 
the  omphalomesenteric  or  vitelline  duct.     During  the  development  of  the  embryo 


Allantofs 


Fig.  11. — Sagittal  Section  of  the  Umbilical  Region  in  a  Human  Embryo  23  mm.  in  Length. 
The  small  drawing  to  the  left,  which  is  of  natural  size,  accurately  depicts  the  relation  of  the  yolk-sac  to  the 
cord  and  amnion.  Its  stalk  is  very  long,  and  the  yolk-sac  has  become  relatively  smaller.  The  umbilical  cord  now 
shows  very  marked  twisting.  The  exoccelomic  cavity  in  the  umbilical  cord  now  contains  practically  all  the  intestine 
with  the  exception  of  the  jejunum  and  descending  colon.  The  distal  portion  of  the  cavity  is  funnel-shaped,  the  apex 
being  directed  away  from  the  embryo.  The  omphalomesenteric  duct  has  disappeared,  but  its  vessels  persist.  The 
small  cystic  spaces  in  the  upper  wall  of  the  cord  mark  the  beginning  obliteration  of  the  exoccelom.  The  umbilical 
vein  has  been  partly  removed  in  order  to  bring  into  view  the  deeper  structures.  The  two  umbilical  arteries,  accom- 
panied by  the  allantois,  are  in  their  usual  position  in  the  lower  part  of  the  cord.  Note  the  slight  spindle-shaped  dila- 
tation of  the  allantois  in  its  course. 


and  its  digestive  tract  the  allantois  has  been  carried  downward  and  backward.  It 
now  opens  into  the  cloaca,  and  can  be  traced  out  in  the  body-stalk  as  far  as  the 
placenta. 

By  the  time  the  embryo  is  3.5  mm.  long  (Fig.  4)  the  amnion  has  completely 
encircled  the  embryo.  The  yolk-sac  has  increased  somewhat  in  size,  is  pear-shaped, 
covered  with  a  tracery  of  blood-vessels,  and  appears  to  have  small,  shallow,  cyst- 


12 


THE    UMBILICUS    AND    ITS    DISEASES. 


like  elevations  on  its  surface.  It  is  still  intimately  connected  with  the  embryo 
through  its  omphalomesenteric  duct,  which  joins  the  body-stalk,  passing  into  the 
amniotic  sac  and  thence  to  the  embryo. 

When  the  embryo  reaches  5  mm.  in  length  (Fig.  5),  the  yolk-sac  is  about  the 


Allanioi  s 


Om.  rnes.  vessels  in  exo-coelom 
Umb.  vein 


Fig.  12. — A  Graphic  Reconstruction  of  the  Umbilical  Region  of  a  Human  Embryo  3  cm.  Long.  (Mall  collec- 
tion, No.  86.) 
The  small  sketch  in  the  right  upper  corner  indicates  the  points  at  which  the  sections  of  the  cord  have  been  made. 
This  stage  marks  the  maximal  development  of  the  exoccelom,  the  intestine  completely  filling  its  cavity.  Section  I, 
the  nearest  to  the  embryo,  gives  a  frontal  view  of  the  narrow  coelomic  ring,  which,  on  account  of  the  solid  tissue  contain- 
ing i  he  vascular  structures  below,  appears  in  the  form  of  a  crescent.  Emerging  from  the  ring  we  see  the  small  intestine 
to  the  right  of  the  embryo,  and  the  large  intestine  to  the  left,  with  the  accompanying  mesentery  between  them.  In 
the  cross-section  of  the  mesentery  are  seen  numerous  sections  of  its  arteries  and  vein.  The  omphalomesenteric  vein 
passes  outside  of  and  above  the  mesentery;  the  omphalomesenteric  artery  comes  from  below,  as  seen  in  Section  II. 
They  soon  leave  the  intestine  and  pass  out  into  the  funnel-shaped  exoccelom. 


same  size.     It  is  now  beginning  to  play  a  minor  role,  and  its  omphalomesenteric 
duct  is  much  smaller  in  caliber. 

In  an  embryo  10  mm.  long  (Fig.  8)  the  yolk-sac  is  found  pushed  to  one  side. 
It  is  now  connected  with  the  extra-amniotic  portion  of  the  umbilical  cord  by  the 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


13 


Fig.  13. — Sagittal  Section  of  the  Umbilical  Region  in  a  Human  Embryo  4.5  cm.  in  Length. 
The  intestine  has  receded  completely  into  the  abdominal  cavity.  The  exoccelomic  cavity,  although  small  in  size 
is  still  clearly  recognizable  in  the  cord,  where  it  shows  spindle-shaped  dilatations.  It  now  contains  only  the  omphalo- 
mesenteric vessels,  which  have  become  embedded  in  its  wall.  The  allantois  (urachus)  is  the  distal  prolongation  of  the 
urinary  bladder,  and  shows  already  the  characteristic  dilatations  noticeable  in  older  embryos  and  occasionally  found 
after  birth.     The  structures  of  the  cord  show  the  characteristic  twisting  of  the  embryo  to  the  right. 


14 


THE    UMBILICUS    AND    ITS    DISEASES. 


attenuated  omphalomesenteric  duct  and  its  blood-vessels.  These  present  a 
twisted  appearance.  The  omphalomesenteric  vessels  still  persist  in  the  cord  near 
the  embryo,  but  the  duct  at  this  point  has  usually  disappeared. 

By  the  time  the  embryo  has  reached  a  length  of  23  mm.  (Fig.  11)  the  yolk-sac  is 
relatively  insignificant,  and,  although  still  attached  to  the  cord,  is  far  removed  from 
the  site  of  its  insertion  into  the  placenta. 

When  the  embryo  is  about  5.5  cm.  in  length  (Fig.  31),  the  yolk-sac,  now  called 


ph-mes.  vein  m  exo-coelom 


exo-coetom 


Fig.  14. — A  Graphic  Reconstruction  of  the  Umbilical  Region  op  a  Human  Embryo  4.5  cm.  in  Length  as  Viewed 

FROM  WITHIN  THE  ABDOMEN. 

Coming  from  below  are  the  two  umbilical  arteries  with  the  urachus  between  them.  Above  is  the  umbilical  vein, 
inclosed  in  a  bulbous  thickening  of  the  surrounding  tissue.  The  body-wall  of  the  embryo  at  the  cord  has  closed,  save 
for  an  irregular  slit.  The  exoccelom  outside  the  general  peritoneal  cavity  dilates,  as  indicated  by  the  dotted  line;  it 
soon  becomes  obliterated.  Plunging  into  the  upper  corner  of  the  exoccelom,  and  adherent  to  its  wall,  are  the  omphalo- 
mesenteric vessels,  accompanied  by  a  thick  cord  of  embryonic  connective  tissue,  which,  near  the  intestine,  has  an  epi- 
thelial center  but  no  lumen.  This  is  undoubtedly  a  remnant  of  the  omphalomesenteric  duct.  The  section  of  the  cord 
shown  above  is  taken  from  near  the  embryo.  It  depicts  the  characteristic  position  of  the  allantois,  and  the  narrow, 
slit-like  termination  of  the  exoccelom  with  the  omphalomesenteric  vein  in  its  wall,  the  artery  having  disappeared. 


the  umbilical  vesicle,  is  a  small,  translucent,  elongated,  and  flattened  cyst,  about 
3  by  5  mm.,  attached  to  the  insertion  of  the  cord  into  the  placenta  by  a  delicate 
vascular  thread — all  that  remains  of  the  omphalomesenteric  structures.  The 
vesicle  remains  about  the  same  size  until  birth.  It  is  then  recognized  as  a  small, 
blunt  or  pear-shaped  cyst,  lying  between  the  amnion  and  placenta  (Fig.  32).  Its 
pedicle  can  be  traced  for  a  variable  distance  in  the  substance  of  the  umbilical  cord. 
In  short,  the  yolk-sac  in  the  very  beginning  of  life  is  an  important  structure. 
From  it  the  allantois  and  the  gastro-intestinal  tract  develop,  the  connecting  link 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


15 


with  the  body  being  the  omphalomesenteric  duct.  The  omphalomesenteric  or 
vitelline  duct  in  time  usually  disappears,  but,  as  will  be  noted  elsewhere,  traces  of 
the  allantois  not  infrequently  persist. 

Those  wishing  for  a  more  detailed  description  of  the  umbilical  vesicle  or  yolk- 
sac,  together  with  the  histologic  findings,  should  read  the  article  by  Arthur  Meyer, 
published  in  1904.  Meyer  studied  the  umbilical  vesicles  of  18  normal  human 
embryos  from  the  Mall  collection.  In  addition  he  examined  a  number  of  patho- 
logic specimens  and  also  some  taken  from  the  placenta  at  birth.  He  pointed  out 
that  the  vesicle  in  the  early  embryo  is  lined  with  one  layer  of  cuboidal  epithelium, 


xl50 


Fig.  15. — Sagittal  View  of  a  Graphic  Reconstruction  of  the  Umbilical  Region  of  a  Human  Embryo  5.2  cm. 

in  Length. 
From  within,  the  relations  of  the  umbilical  arteries  to  the  vein  are  clearly  seen.  They  surround  the  funnel-shaped 
remnant  of  the  exoccelom.  No  trace  of  the  omphalomesenteric  vessels  is  to  be  seen  in  the  peritoneal  cavity,  but  in 
cross-sections  of  the  cord  near  the  embryo  the  lumen  of  the  umbilical  vein  still  persists,  as  indicated  in  the  small  draw- 
ing to  the  left.  It  is  embedded  in  the  wall  of  the  exoccelom,  but  has  no  connection  with  any  other  vascular  structure. 
The  bladder  bulges  out  between  the  umbilical  arteries.  The  urachus  (allantois)  passes  out  into  the  cord  between  and 
below  the  umbilical  arteries.     This  is  the  characteristic  arrangement.     The  urachus  shows  two  dilatations. 

and  that,  passing  out  into  the  walls  of  the  vesicle,  are  little  bays  or  tubules.  He 
also  drew  attention  to  the  calcareous  material  found  in  the  cavity  of  the  vesicle  at 
term.     A  further  consideration  of  this  subject  here  would  carry  us  too  far  afield. 


THE  BODY-STALK. 
In  the  early  stages  the  embryo  rests  upon  the  body-stalk.  This  fact  is  clearly 
shown  in  Fig.  1.  The  stalk  at  this  period  is  much  larger  than  the  embryo.  It 
also  supports  the  yolk-sac  and  the  amnion,  and  through  it  the  blood-vessels  of  the 
placenta  pass  to  and  from  the  embryo.  When  the  embryo  reaches  about  1.7  mm. 
in  length  (Fig.  2) ,  the  body-stalk  is  found  to  be  still  of  about  the  same  size,  but  its 


16  THE    UMBILICUS    AND    ITS    DISEASES. 

upper  or  embryonic  portion  passes  more  ventral  ward  and  its  upper  end  lies  almost 
directly  below  the  hind-gut.  Its  blood-vessels  have  increased  materially  in  diam- 
eter. With  the  development  of  the  embryo  and  the  expansion  of  the  amnion  the 
body-stalk  becomes  longer  and  assumes  more  the  appearance  of  a  cord,  which  is 
inserted  into  the  ventral  surface  of  the  embryo.  This  is  particularly  well  seen  in 
Fig.  3,  which  is  from  an  embryo  2.5  mm.  long. 

When  the  embryo  reaches  a  length  of  3.5  mm.  (Fig.  4),  the  body-stalk  closely 
resembles  an  umbilical  cord.  Together  with  the  omphalomesenteric  duct,  it 
passes  into  the  amniotic  cavity,  where  the  two  fuse  and  become  the  umbilical  cord. 

In  an  embryo  5  mm.  long  (Fig.  5)  the  body-stalk,  as  such,  lying  outside  the 
amniotic  sac,  is  very  short,  the  amnion  lying  in  almost  direct  contact  with  the 
chorion. 

The  intra-amniotic  portion  of  the  body-stalk  will  be  considered  when  we  come 
to  speak  of  the  umbilical  cord. 


THE  ALLANTOIS  AND  URACHUS. 

The  allantois  is  one  of  the  first  structures  differentiated  in  the  embryo.  For 
example,  in  an  embryo  0.7  mm.  long  (Fig.  1)  it  is  recognized  as  a  recess  of  the 
yolk-sac  extending  into  the  body-stalk.  It  rapidly  increases  in  length,  and  in  an 
embryo  1.7  mm.  long  has  penetrated  deeply  into  the  body-stalk  (Fig.  2). 

In  an  embryo  2.5  mm.  long  (Fig.  3)  a  portion  of  the  yolk-sac  has  been  definitely 
differentiated  into  the  digestive  tract.  Its  caudal  portion  has  been  carried  down- 
ward and  forward,  terminating  in  the  cloaca.  The  allantois  now  starts  from  the 
cloaca,  and,  after  curving  upward,  passes  outward  in  the  body-stalk  to  end  in  a 
bulbous  extremity  near  the  placenta. 

In  the  embryo  5  mm.  long  (Fig.  5)  it  still  communicates  with  the  cloaca,  and, 
after  emerging  from  the  abdomen,  passes  out  in  the  body-stalk,  which  now  forms 
an  integral  part  of  the  umbilical  cord. 

By  the  time  the  embryo  is  7  mm.  long  the  allantois  has  been  partially  separated 
from  the  bowel  by  the  urorectal  septum.  The  lower  portion  of  the  allantois  has 
been  converted  into  the  bladder  (Fig.  7),  and  its  upper  part  now  passes  off  from  the 
fundus,  extending  upward  and  forward  and  passing  out  in  the  cord  as  heretofore. 

Fig.  6,  also  from  an  embryo  7  mm.  long,  shows  the  relation  of  the  allantois  to 
the  umbilical  arteries.  It  lies  between  and  slightly  below  them,  and,  whenever 
found  either  in  the  early  or  in  the  late  stages  of  fetal  life  or  after  birth,  it  in- 
variably occupies  this  position. 

The  patency  of  the  allantois  in  the  umbilical  cord  varies  markedly.  Some- 
times, even  in  the  early  embryo,  the  duct  may  be  impervious  at  some  points  and 
dilated  at  others.  Thus,  in  an  embryo  12.5  mm.  long  (Fig.  9)  the  allantois  is  oblit- 
erated in  a  cross-section  of  the  cord  near  the  fetus;  in  a  second  section  a  little  farther 
out  in  the  cord  it  is  seen  as  a  somewhat  flattened  tube,  nearly  as  large  as  an  umbili- 
cal artery;  in  a  third  section  of  the  cord,  still  farther  out,  the  allantois  forms  an 
irregular  sac,  the  distal  end  of  which  terminates  in  a  thread-like  process. 

Examination  of  an  embryo  23  mm.  long  (Fig.  11)  shows  a  urachus  patent  at  the 
point  where  it  emerges  from  the  abdomen.  It  then  becomes  impervious,  and  farther 
out  forms  a  delicate,  spindle-like  dilatation. 

The  intra-abdominal  portion  of  the  allantois  in  the  well-differentiated  embryo  is 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION, 


17 


called  the  urachus.  Fig.  13,  from  an  embryo  4.5  cm.  long,  shows  the  urachus  passing 
upward  from  the  summit  of  the  bladder.  In  some  places  it  is  recognized  as  a 
slender  filament,  but  in  its  course  it  has  two  delicate,  spindle-like  dilatations.  The 
allantois  in  the  cord  contains  several  similar  dilatations. 

As  the  embryo  becomes  larger  the  bladder  may  extend  somewhat  high  up,  reach- 


o 


:tus 


I V 


Fig.  16. — Intra-abdominal  View  of  the  Umbilical  Region"  of  a  Human  Embryo  6.5  cm.  in"  Length.  (X  9.) 
A  portion  of  the  abdominal  wall,  including  the  umbilicus,  has  been  excised.  The  bladder  lies  between  the  umbilical 
arteries  and  gradually  diminishes  in  caliber  toward  the  umbilicus.  This  is  clearly  seen  in  the  cross-section  projected 
in  the  lower  picture.  The  umbilical  vein  emerges  from  the  abdominal  wall  just  above  the  umbilical  region.  The 
umbilical  opening  is  closed,  its  former  position  being  now  recognized  as  several  shallow  pits  in  the  peritoneum.  To  the 
left  is  a  cross-section  of  the  flattened  cord,  containing,  in  addition  to  the  umbilical  vessels,  the  allantois,  which  is  obliter- 
ated at  this  point.     There  are  no  remnants  of  either  exocoelom  or  omphalomesenteric  structures. 


ing  almost  to  the  umbilicus.  This  is  seen  in  Fig.  15,  from  an  embrj-o  5.2  cm.  long. 
The  urachus  is  short,  and  just  where  it  enters  the  cord  is  seen  a  spindle-shaped 
dilatation.  A  similar  dilatation  is  noted  in  the  outer  or  allantoic  portion.  The 
upward  extension  of  the  bladder  is  well  shown  in  Fig.  16.  from  an  embryo  6.5  cm. 
in  length.  A  cross-section  a  little  below  the  umbilicus  shows  that  the  bladder  at 
3 


18 


THE    UMBILICUS    AND    ITS    DISEASES. 


Allantois  J| 


a 


^ 


iJ-COt  IOT0 


s    *& 


kllantois  i Urachus 


o  «*  o 


.....  t><-o  !»i .. 

Fig.  17. — Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  7.5  cm.  Long.  (X6.) 
In  this  case  the  allantois  (urachus)  is  very  narrow,  as  seen  in  the  cross-section  of  the  abdominal  wall,  as  well  as 
in  the  cross-section  of  the  cord.  The  tissues  containing  the  umbilical  arteries  and  urachus  are  attached  to  the  abdom- 
inal wall  by  a  well-defined  but  narrow  mesentery.  This,  however,  is  exceptional.  At  the  umbilicus  the  coelomic  ring 
is  obliterated  and  appears  as  a  crescent  between  the  umbilical  arteries  and  vein.  Farther  out  in  the  cord,  however 
the  exocoelom  can  still  be  clearly  seen  as  a  small,  star-shaped  cavity.     The  cord  is  markedly  twisted. 


■ 


Fig.  18. — Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  9  cm.  in  Length.  (X  7.) 
The  urachus  shows  a  spindle-shaped  widening  at  its  upper  portion.  Microscopically  it  could,  however,  be  traced 
in  its  continuity  not  only  to  the  umbilicus,  but  also  out  into  the  cord,  as  indicated  by  the  cross-section  of  the  cord, 
where  it  occupies  its  characteristic  position  in  relation  to  the  umbilical  arteries.  The  umbilical  ring  is  entirely  bridged 
over  by  a  band  of  subperitoneal  connective  tissue.  A  considerable  space  exists  between  the  umbilical  vein  and  the 
umbilical  arteries.  This  arrangement  closely  resembles  that  noted  in  the  adult.  There  is  no  trace  of  the  omphalo- 
mesenteric structures  in  the  cord. 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


19 


Omph.rnes. 
vessels 


X2  00 


I  '  /'i       J 

f       Vt     * 


%   1^/ 


t 

'a 


Mu 


scie 


:  •        -        *        Obhteratea 


lantois 


Fig.  19. — Intra-abdominal  View  ofjhe  Umbilical  Region  in  a  Human  Embryo  10  cm.  in  Length.  (X  6.) 
The  urachus  is  very  narrow,  but  is  continued  out  into  the  cord  (allantois).  In  this  cross-section  of  the  cord  it  was 
recognized  as  a  nest  of  polygonal  cells  devoid  of  a  lumen,  and  surrounded  by  several  bundles  of  well-defined  non-striped 
muscle.  This  muscle  surrounded  the  urachus  down  to,  and  merged  into,  that  of  the  bladder.  The  umbilical  ring  is 
completely  sealed  over  by  a  broad  connective-tissue  band.  In  the  cross-section  of  the  cord  no  remnants  of  the  exocce- 
lomic  cavity  were  demonstrable,  but  in  its  place  were  traces  of  blood-vessels,  evidently  remains  of  the  omphalo- 
mesenteric vessels. 


Omph,  tries. 
vessels 


Allantois 


Fig.  20. — Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  12  cm.  Long.  (X  3.) 
The  bladder  is  unusually  distended,  and  reaches  almost  to  the  umbilicus.  Both  it  and  the  umbilical  vessels  have 
a  well-defined  mesenteric  attachment  to  the  abdominal  wall.  The  bladder  was  closed  above,  and  the  urachus  was 
recognized  as  a  solid  cord.  In  the  umbilical  cord,  however,  the  allantois  showed  here  and  there  traces  of  a  lumen. 
The  umbilical  ring  was  completely  closed.  At  its  site  was  a  crescent-shaped  pit.  The  exocoelom  had  disappeared 
in  the  cord,  but  traces  of  the  omphalomesenteric  vessels  were  still  visible. 


20 


THE    UMBILICUS    AND    ITS    DISEASES. 


this  point  is  almost  tubular.     It  gradually  tapers  off,  and  ends  just  below  the 
umbilical  depression. 

It  would  seem,  from  an  examination  of  numerous  embryos,  that  the  degree  of 
extension  of  the  bladder  upward  is  subject  to  much  variation.  Fig.  17  is  from  an 
embryo  7.5  cm.  long.  The  bladder  is  evidently  low.  Cross-sections  near  the  blad- 
der and  also  in  the  neighborhood  of  the  umbilicus  show  a  patent  urachus,  and  a 


Fig.  21. — Intra-abdominal  View  of  the  Umbilical  Region  in  a  Human  Embryo  12  cm.  in  Length.  (X  3.) 
The  urachus  gradually  narrows,  but  microscopically  could  be  traced  as  a  cord  for  a  considerable  distance  out  into 
the  umbilical  cord.  In  the  main  it  was  solid,  but  here  and  there  appeared  to  have  a  lumen.  The  umbilical  vessels 
now  have  very  well-developed  muscular  coats,  the  inner  longitudinal  layer  being  especially  thick.  The  umbilical  ring 
shows  a  puckering,  possibly  due  to  the  hardening.  It  is  obliterated.  Note  the  oval,  funnel-shaped  depression  between 
the  umbilical  arteries  and  vein.  Adherent  to  the  bottom  of  this  is  a  cord  which  was  attached  to  a  loop  of  small  bowel. 
This  is  the  remnant  of  the  omphalomesenteric  duct  or  vessels.  In  the  cord  the  exoccelom  is  recognized  as  a  slit-like 
cavity  traversed  by  delicate  trabecular  of  young  connective  tissue.  At  one  side  of  this  slit  is  a  dense  mass  of  tissue 
containing  the  patent  omphalomesenteric  vessels,  and  the  duct  which  appeared  as  a  mass  of  epithelial  cells  but  showed 
no  lumen. 


cross-section  of  the  cord,  at  some  distance  from  the  body,  shows  that  the  allantois 
(urachus)  is  patent  here  also. 

In  Fig.  19,  from  an  embryo  10  cm.  long,  the  cord  near  the  umbilicus  shows  the 
allantois,  which,  however,  is  obliterated  and  represented  by  a  solid  nest  of  polygonal 
cells  surrounded  by  cross-sections  of  groups  of  non-striped  muscle,  showing  that  the 
urachus  has  a  longitudinal  outer  muscular  covering. 

Figs.  22  and  23,  from  an  embryo  12  cm.  long,  are  very  instructive.  Fig.  22 
shows  a  rross-section  of  the  abdominal  wall  made  near  the  umbilicus.     Here  the 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


21 


urachus  is  very  small  and  almost  solid.  In  a  section  of  the  cord,  at  a  short  distance 
from  the  embryo,  the  allantois  is  found  to  be  patent  and  surrounded  by  one  or 
more  layers  of  the  characteristic  polygonal  cells.  This  polygonal  character  of  the 
cells  is  also  clearly  shown  in  Fig.  23,  which  was  taken  from  the  same  cord  close  to 
the  abdominal  wall.  In  Fig.  20,  also  from  an  embryo  12  cm.  long,  the  bladder 
extends  almost  to  the  umbilicus. 

Figs.  28  and  29  show  the  relation  of  the  bladder  to  the  umbilicus  in  embryos  of 
five  and  about  six  and  one-half  months  respectively:  in  both  cases  it  extended 
almost  to  the  umbilicus. 


f/^3«-o^ 


Allan: 


X150 


'if(t. 


Section  shown 


Ui 


r~^ 


Fig.  22. — Ixtra-abdomixal  View  of  the  Umbilical  Region"  in  a  Human  Embryo  12  cm.  in  Lexgth.     (X  3.) 

The  urachus  is  very  narrow,  as  seen  in  the  lower  cross-section.  In  the  cord,  however,  it  (the  allantois)  has  at 
several  points  a  definite  lumen  lined  with  polygonal  cells.  The  umbilical  ring  is  completely  closed.  Fig.  23  gives  an 
external  view  of  the  umbilical  region  of  the  same  embryo. 


From  the  foregoing  it  is  seen  that  the  allantois  develops  from  the  yolk-sac; 
that  it  is  one  of  the  earliest  structures  to  make  its  appearance,  and  that,  after  a 
time,  it  is  carried  downward  and  forward,  coming  off  from  the  cloaca.  The  bladder 
develops  from  the  lower  portion  of  the  allantois.  The  upper  portion  of  the  allantois 
is  continued  to  the  umbilicus  and  then  passes  to  the  cord.  Its  intra-abdominal 
portion  is  now  called  the  urachus. 

The  urachus  and  allantois  soon  become  solid  cords  in  a  part  of  their  course, 
but  show  an  inherent  tendency  to  develop  spindle-like  dilatations  at  irregular 
intervals.  These  dilatations  are  characteristic  of  the  urachus  and  allantois,  and 
it  should  occasion  no  surprise  if  they  are  found  at  any  period  in  the  development  of 


22 


THE    UMBILICUS    AND    ITS    DISEASES. 


the  embryo.  They  undoubtedly  persist  in  many  persons 
and  account  for  the  small  cysts  not  infrequently  noted 
at  operation.  That  the  urachus  occasionally  remains  patent  at  birth  is 
attested  by  the  number  of  children  with  a  urinary  umbilical  fistula  at  birth.  This 
phase  is  discussed  at  length  in  Chapter  XXIX. 

The  tube  composing  the  urachus  and  allantois  is  lined  with  from  one  to  three 


:y^^~7~~^- 

'0( 

;  M 

i        u 

'■;\' 

V 

%   ■           \     :  - 

r  Mk 

; 

■■■■     v<m 

%V%o'-    a*     f0i 


OmbVi.  mes 
ducT  *  ve«<»l 

•CX=r   -                                  .. 

c 

i$ '';■ 

■  ■■..,        ( 

Ornph.mes. 
vessels  + 
duct  X  2.00       ' 

1 
Allaniois 

Cord  ai  uvrioilicus  X  8 


Allaniais 
X200 


Fig.  23. — Cross-section  of  the  Umbilical  Cord  at  the  Umbilicus  in  a  Human  Embryo  12  cm.  in  Length.     (X  8.) 

This  drawing  is  also  from  the  embryo  shown  in  Fig.  22  In  the  upper  figure  the  cord  has  been  cut  across  about 
1  mm.  from  the  abdominal  wall.  The  umbilical  arteries  are  surrounded  by  Wharton's  jelly.  In  the  triangle  below 
and  between  them  is  a  small,  opaque  cord,  the  allantois.  Above  the  right  umbilical  artery  an  irregular  lumen,  con- 
tinued as  a  slit  on  either  side,  represents  the  disappearing  exocoelomic  cavity.  The  slit-like  portion  above  the  vein  is 
already  partially  organized.  Surrounding  the  entire  mass  is  a  dense  layer  of  connective  tissue,  and  external  to  this  is 
the  subcutaneous  adipose  tissue  traversed  by  numerous  cutaneous  vessels.  The  lower  picture  shows  a  microscopic 
section  still  nearer  the  embryo.  The  slit-like  exoccelom  (c,  c)  stands  out  much  more  clearly.  In  its  upper  wall  are 
seen  the  omphalomesenteric  vessels  and  duct.  An  enlarged  view  of  these  is  given  on  the  left.  Here  the  omphalomesen- 
teric duct  is  recognized  as  a  solid  nest  of  epithelial  cells.  The  allantois  is  visible  slightly  below  and  between  the  umbilical 
arteries,  whose  lumina  are  star-shaped.  The  drawing  to  the  right  shows  that  the  allantois  is  patent  and  surrounded  by 
polygonal  cells.     The  allantois  here  is  inclosed  in  embryonic  connective  tissue  which  is  devoid  of  muscle. 

layers  of  transitional  epithelium,  similar  to  that  of  the  bladder,  and  is  surrounded 
by  a  coat  of  longitudinal  non-striped  muscle. 


THE  CCELOM. 
"Without  a  clear  conception  of  the  exoccelom,  the  early  embryologic  appearances 
of  the  umbilical  region  cannot  well  be  understood.     In  the  embryo  1.7  mm.  long 
(Fig.  2)  a  small  depression  exists  at  or  near  the  point  where  the  yolk-sac  and  amnion 
merge.     The  arrows  indicate  the  direction  that  the  exoccelom  will  later  follow. 


EMBRYOLOGY    OF   THE    UMBILICAL    REGION.  23 

When  the  embryo  has  reached  a  length  of  2.5  mm.  (Fig.  3),  the  exoccelom  has 
extended  inward  between  the  yolk-sac  and  amnion;  it  now  completely  encircles  the 
omphalomesenteric  duct,  and  has  extended  upward  toward  the  stomach  and  down- 
ward toward  the  cloaca.  From  this  picture  it  can  be  readily  understood  why  at  a 
later  stage  the  omphalomesenteric  duct  and  its  vessels  lie  in  the  exoccelomic  cavity 
in  the  umbilical  cord. 

The  exoccelom,  which  has  extended  into  the  embryo,  later  unites  with  the 
ccelomic  or  pleuroperitoneal  cavity. 

By  the  time  the  embryo  reaches  a  length  of  5  mm.  (Fig.  5)  the  body-stalk  and 
the  omphalomesenteric  duct  with  its  vessels  have  merged  into  the  umbilical  cord, 


Fig.  24. — Internal  View  of  the  Umbilical  Region  in  a  Human  Embryo  15  cm.  Long.    (X  4. 

The  urachus  is  very  much  attenuated,  but   is  still   continuous  as  a  cord,  with  the  partially  obliterated  allantoisseen 

in  the  cross-section  of  the  cord.     The  umbilical  ring  is  closed  by  a  firm  transverse  fibrous  band. 


and  with  the  fusion  it  is  but  natural  that  the  omphalomesenteric  structures  should 
still  be  surrounded  by  the  exoccelom.  The  portion  of  the  ccelom  outside  the  ab- 
domen is  referred  to  as  the  exoccelom,  whereas  the  intra-abdominal  portion,  with 
which  it  is  still  continuous,  is  called  the  ccelom. 

As  the  embryo  continues  to  develop,  the  omphalomesenteric  duct,  which  is  still 
a  part  of  the  small  bowel  and  lies  in  the  exoccelom,  evidently  makes  traction  on  the 
gut  and  draws  it  out  into  the  exoccelomic  cavity.  In  an  embryo  7  mm.  long  this 
cavity  (Fig.  6)  contains  the  cecum.  In  another  embryo  of  the  same  length  (Fig.  7) 
the  free  opening  between  the  ccelom  and  the  exoccelom  of  the  cord  is  clearly 
depicted. 

When  the  embryo  reaches  a  length  of  10  mm.  (Fig.  8),  the  small  bowel,  which 


24 


THE    UMBILICUS    AND    ITS    DISEASES. 


Omph  rties.v 


Meckel^,  dlvertitulun 
Uirib.  arteries 


Bladder 


Fig.  25. — A  Composite  Representation  of  Abnormal  Umbilical  Structures  Based  on  the  Work  op  Keibel, 

Lowy,  and  Others. 
The  bladder  gradually  tapers  into  the  urachus  and  is  obliterated  at  the  umbilicus.     In  the  cord  are  seen  numer- 
ous dilatations  of  the  allantois  (urachus).     The  omphalomesenteric  duct  (Meckel's  diverticulum)  goes  to  the  umbilicus, 
where  it  becomes  lost  in  the  ecelomic  funnel.     It  is  accompanied  by  the  omphalomesenteric  vessels.     The  artery 
terminates  in  its  wall;  the  vein  continues  and  becomes  lost  in  the  exoccelom  of  the  cord. 


x!50 

Obliterated  ^p-  /%%& 

-   ntois  Z?%i.         <W^vsticallantoi 


Fig.  26. — A  Composite  Representation  of  Abnormal  Umbilical  Structures  Based  on  the  Work  of  Keibel, 

Lowy,  and  Others. 
The  allantois  in  the  cord  shows  one  large  and  one  small  dilatation.     The  large  dilatation  is  lined  with  one  layer  of 
flattened  epithelium.     The  obliterated  cord  between  the  dilatations  consists  of  closely  packed  epithelial  cells.     The 
inner  end  of  the  omphalomesenteric  duct  persists  as  a  sac-shaped  Meckel's  diverticulum.     Its  vessels  continue  on  into 
the  ecelomic  funnel  at  the  umbilicus,  but  become  lost  in  the  exoccelom  of  the  cord. 


Umb.V. 


Fig.  27. — A  Composite  Representation  of  Abnormal  Umbilical  Structures  Based  on  the  Work  of  Keibel, 

Lowy,  and  Others. 
The  allantois  shows  numerous  spindle-shaped  dilatations  in  the  cord,  with  obliterated  portions  between.     The  omphalo- 
mesenteric duct  has  disappeared,  but  the  vessels  still  persist,  the  vein  continuing  farther  out  than  the  artery. 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


25 


.>  X?Py 


Fig.  28. — The  Umbilical  Region  in  a  Fetus  about  Five  Months  Old  Viewed  from  the  Left. 
Note  the  portion  of  the  triangular  falciform  Ligament  between  the  umbilical  vein  and  the  ventral  abdominal  wall. 
The  bladder  and  allantois  (urachus)  are  in  the  usual  position;  the  latter  is  becoming  obliterated.  In  the  cord  it  appears 
below  and  between  the  umbilical  arteries.  In  the  center  of  the  cord  is  the  sickle-shaped  lumen  of  the  exoccelom,  which, 
however,  is  bridged  over  in  many  places  by  delicate  strands  of  connective  tissue.  In  the  abdomen  a  shallow  pit  still 
marks  the  position  of  the  umbilical  ring. 


Fig.  29. — Side  and  Posterior  Views  of  the  Umbilical  Region  in  a  Fetus  of  Six  to  Seven  Months. 
The  left  figure  shows  the  characteristic  recesses  (a,  b)  between  the  umbilical  artery  and  the  abdominal  wall.  (See 
also  Figs.  17,  20,  and  24.)  The  bladder  reaches  nearly  to  the  umbilicus,  the  urachus  being  very  short.  In  the  section 
of  the  cord  shown,  neither  the  allantois  nor  the  omphalomesenteric  structures  could  be  demonstrated.  The  falciform 
ligament  of  the  liver  is  very  short ;  hence  the  close  union  between  the  umbilical  vein  and  the  abdominal  wall.  The 
umbilical  ring  is  closed  by  a  broad  band  of  connective  tissue.  The  figure  to  the  right  shows  the  characteristic  triangular 
shape  of  the  upper  part  of  the  bladder,  and  also  its  sudden  narrowing  into  the  urachus  above. 


26  THE    UMBILICUS    AND    ITS    DISEASES. 

consists  of  one  long  loop,  is  found  extending  for  quite  a  distance  out  into  the  cord. 
It  lies  free  in  the  exoccelom,  and  is  accompanied  by  the  vessels  of  the  omphalomes- 
enteric duct.  A  somewhat  similar  picture  was  noted  in  the  cord  of  an  embryo  12.5 
mm.  long  (Fig.  9). 

With  the  continued  development  of  the  embryo  and  the  simultaneous  increase 
in  the  number  of  the  intestinal  loops,  more  and  more  of  the  intestine  develops  in  the 
exoccelomic  cavity.  Fig.  10  represents  the  findings  in  an  embryo  18  mm.  long; 
Fig.  11,  those  in  an  embryo  23  mm.  in  length. 

The  maximal  size  of  the  exoccelomic  cavity  in  the  cord  is  probably  reached  when 
the  embryo  is  about  30  mm.  in  length  (Fig.  12).  In  this  picture  the  exoccelomic 
cavity  appears  to  the  right  of  the  solid  portion  of  the  cord.  It  contains  nearly  all 
of  the  bowel. 

By  the  time  the  embryo  has  reached  a  length  of  4.5  cm.  (Figs.  13  and  14)  the 
intestine  has  receded  into  the  abdomen  and  a  section  of  the  cord  near  the  body  will 
reveal  only  a  trace  of  the  exoccelomic  cavity.  This  is  recognized  as  a  more  or  less 
triangular  slit,  containing  only  the  omphalomesenteric  vessels.  In  Fig.  15,  taken 
from  an  embryo  5.2  cm.  long,  a  small  exoccelomic  cavity  still  exists,  and  adherent  to 
its  upper  wall  is  the  patent  omphalomesenteric  vein. 

Even  in  embryos  12  cm.  long  (Figs.  21  and  23)  slit-like  traces  of  the  exoccelom 
may  be  found  in  the  cord  near  the  fetus. 

To  the  clinician  the  chief  interest  in  the  exoccelom 
lies  in  the  fact  that  in  rare  instances  the  intestine  does 
not  entirely  recede,  but  remains  incarcerated  in  this 
extra-abdominal  cavity,  giving  rise  to  the  large  ven- 
tral  hernise   occasionally   noted    at    birth. 


THE  UMBILICAL  VESSELS. 

These  consist  of  two  arteries,  and  in  the  beginning  of  two  veins,  the  right  and 
the  left.  The  left  vein  is  the  larger  and  persists;  the  right  disappears  before  the 
embryo  is  10  mm.  long. 

Even  in  the  very  early  embryo,  0.7  mm.  long  (Fig.  1),  the  umbilical  arteries  and 
veins  are  seen  in  the  body-stalk.  At  this  stage  they  convey  the  placental  blood 
to  and  from  the  primitive  embryo.  By  the  time  the  embryo  is  1.7  mm.  long 
(Fig.  2)  the  umbilical  arteries,  after  passing  along  the  primitive  digestive  tract, 
enter  the  body-stalk  beside  the  allantois  and  divide  into  many  placental  branches. 
Just  before  entering  the  embryo,  the  umbilical  vein  divides  into  two  branches. 
These  pass  up  the  right  and  left  abdominal  wall  to  unite  with  the  hepatic  circula- 
tion. 

In  the  embryo  2.5  mm.  in  length  (Fig.  3),  the  cord  is  seen  to  contain  two  um- 
bilical arteries  and  one  umbilical  vein,  which  at  the  embryo  divides  into  two  trunks, 
the  right  and  the  left.  The  umbilical  arteries  pass  downward  toward  the  caudal 
extremity  of  the  embryo ;  the  vein  goes  upward  toward  the  liver. 

When  the  embryo  has  reached  5  mm.  in  length  (Fig.  5),  we  still  find  the  two 
umbilical  arteries,  which,  after  passing  along  the  cord,  enter  the  ventral  surface  of 
the  embryo  and  pass  downward. 

Fig.  6,  from  an  embryo  7  mm.  long,  shows  clearly  the  relations  of  the  right  and 
left  umbilical  veins.     The  left  umbilical  vein  is  very  large  and  runs  upward  to  the 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


27 


liver.  The  right  vein  is  much  smaller,  lies  partly  embedded  in  the  abdominal  wall, 
and  is  soon  completely  lost. 

In  the  embryo  23  mm.  long  (Fig.  11)  the  umbilical  vein  is  clearly  seen  entering 
the  substance  of  the  liver.  The  umbilical  arteries,  in  the  cord  as  well  as  in  the 
abdomen,  lie  on  either  side  of  the  allantois.     They  pass  downward  to  the  pelvis. 

In  the  embryo  4.5  cm.  long  (Fig.  13)  the  vein  is  seen  at  the  umbilicus,  curving 
from  the  lower  to  the  upper  portion  of  the  cord,  and  passing  directly  into  the  sub- 
stance of  the  liver,  which  at  this  time  reaches  almost  to  the  umbilicus.  The  um- 
bilical arteries  at  this  period  in  the  development  of  the  embryo,  after  passing  to 
either  side  of  the  allantois  (urachus),  skirt  along  each  side  of  the  bladder.  They 
originate  from  the  lower  portion  of  the  aorta. 

The  subsequent  relation  of  the  umbilical  vessels  is  clearly  depicted  in  Figs.  28 


Fig.  30. — Theee  Diagrams  of  the  Umbilical  Ring  and  its  Significance  in  the  Development  of  Ventral  Hernia. 

I.  Dissection  of  the  umbilical  ring  in  a  human  embryo  eight  months  old,  viewed  from  within.  The  peritoneum 
and  subperitoneal  connective  tissue,  containing  a  small  amount  of  fat,  have  been  carefully  removed,  exposing  a  funnel- 
shaped  opening  above  and  to  the  right  of  the  umbilical  arteries.  The  umbilical  vein  lies  to  the  left  of  this  weak  spot. 
The  umbilical  arteries  are  the  strongest  structures  in  the  wall  of  the  ring,  and  a  hernial  protrusion  usually  occurs  above 
or  to  one  side  of  them.  Occasionally  the  umbilical  vein  is  situated  to  the  right  of  the  ring,  in  which  case  the  weak 
spot  would  be  on  the  left  side. 

II.  Side-view  of  the  umbilical  ring,  showing  the  favorite  position  of  the  small  hernial  protrusion  often  seen  in  new- 
born babes. 

III.  A  larger  hernia,  representing  a  later  stage  of  the  same  type.  Note  how  the  umbilicus  becomes  lodged  at  the 
lower  portion  of  the  hernial  pouch. 


and  29.  The  relation  of  the  umbilical  vessels  at  term  is  well  shown  in  Fig.  30. 
The  umbilical  vein  is  of  large  size,  and  passes  directly  from  the  umbilicus  to  the 
substance  of  the  liver.  It  is  supported  by  the  suspensory  ligament  of  the  liver,  as 
is  graphically  shown  in  Figs.  28  and  29.  The  umbilical  arteries  he  on  either  side 
of  the  urachus,  pass  downward  on  each  side  of  the  bladder,  and  are  connected  with 
the  anterior  division  of  the  internal  iliac  arteries.  After  birth  the  distal  portions 
of  their  lumina  become  narrower,  and  the  vessels  finally  appear  as  the  obliterated 
hypogastric  arteries.     Their  last  pervious  branches  are  the  superior  vesical  arteries. 

It  was  along  the  umbilical  vein  and  the  umbilical 
arteries  that  infections  of  the  new-born  were  so  prone 
to  occur  in  preaseptic   days.     (See  Chapter  III.) 

The  inner  appearance  of  the  umbilicus  at  birth  is  shown  in  Fig.  32.     Shortly 


28 


THE    UMBILICUS    AND    ITS    DISEASES. 


after  birth  the  umbilical  vein  and  the  umbilical  arteries  become  impervious  (Fig. 
61).  In  the  adult  the  thickened  outer  edge  of  the  suspensory  ligament  of  the  liver 
represents  what  remains  of  the  umbilical  vein;  below  the  umbilicus  are  three  cords 
which  are  usually  solid,  the  central  one  passing  to  the  summit,  the  others  to  the 
right  and  left  of  the  bladder.  These  three  cords  are  the  remnants  of  the  urachus 
and  of  the  umbilical  arteries. 


Fig.  31. — The  Appearance  of  the  Yolk-sac  (Umbilical  Vesicle)  in  a  Pregnancy,  with  the  Embryo  5.5  cm.  Long. 
The  chorion  has  been  split  and  turned  back  on  the  uterine  wall.  The  amniotic  cavity  is  still  intact,  appearing  as 
a  tensely  filled  oval  cyst  containing  the  embryo.  Coming  from  the  placental  attachment  of  the  umbilical  cord  is  a 
delicate  vaseular  thread  which  passes  to  the  flattened,  yellowish,  opaque  yolk-sac,  now  referred  to  as  the  umbilical 
vesicle.     It  remains  approximately  this  size  until  birth.      (See  Fig.  32.) 


THE  UMBILICAL  CORD. 

In  the  very  early  embryo,  as  shown  in  Figs.  1  and  2,  there  is  no  umbilical  cord 
as  such,  but  it  is  represented  by  its  chief  constituent,  the  body-stalk. 

By  the  time  the  embryo  reaches  2.5  mm.  in  length  there  has  come  into  existence 
what  might  be  termed  the  primitive  cord  (Fig.  3).  This  is  composed  of  the  omphalo- 
mesenteric duct  and  the  body-stalk,  both  of  which  pass  into  the  ventral  surface 
of  the  embryo.  The  omphalomesenteric  duct  occupies  the  upper  or  fragile  part  of 
the  cord,  and  is  surrounded  by  exoccelom.  The  lower  and  firmer  part  of  the  cord 
contains  the  umbilical  arteries,  the  umbilical  vein,  and  the  allantois. 

When  the  embryo  reaches  3.5  mm.  in  length  (Fig.  4),  the  amnion  has  com- 
pletely encircled  the  embryo.     Outside  the  amniotic  sac  the  omphalomesenteric 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION. 


29 


duct  and  body-stalk  are  separate,  but  within  the  sac  they  have  become  more  or  less 
fused,  forming  the  umbilical  cord. 

In  the  embryo  5  mm.  long  this  fusion  of  the  cord  is  clearly  seen  (Fig.  5).  The 
outer  walls  of  the  cord  show  some  degree  of  organization.  In  the  upper  part  of  the 
cord  is  the  exoccelomic  cavity,  communicating  with  the  intra-abdominal  portion, 
and  containing  the  omphalomesenteric  duct  and  its  vessels.  In  the  lower  part  of 
the  cord  are  the  component  parts  of  the  body-stalk,  the  umbilical  vein,  the  two 
umbilical  arteries,  and  the  allantois. 


Fig.  32. — The  Umbilical  Region,  the  Cord,  and  the  Placenta  at  Teem.     (About  half  natural  size.) 
The  greater  part  of  the  cord  has  been  omitted  as  irrelevant.     The  yolk-sac  still  persists  as  the  umbilical  vesicle,  be- 
tween the  amnion  and  the  chorion.     Its  duct,  however,  after  traveling  a  short  distance,  becomes  lost  in  the  cord. 


A  similar  picture  is  shown  in  the  embryo  7  mm.  long  (Figs.  6  and  7).  In 
the  former  picture  it  will  be  noted  that  the  exoccelomic  cavity,  that  is,  the  portion 
in  the  cord,  has  increased  in  size,  and  that  it  contains,  in  addition  to  the  omphalo- 
mesenteric duct,  a  small  portion  of  the  bowel.  The  umbilical  arteries  lie  in  the  lower 
portion  of  the  cord,  and  between  them,  and  at  a  slightly  lower  level,  is  the  allantois. 
The  umbilical  vein  usually  lies  to  the  left  of  the  arteries  (to  the  right  in  the 
picture) . 

When  the  embryo  is  10  mm.  in  length  (Fig.  8) ,  the  vein  lies  in  the  upper  wall 
of  the  cord.     The  exoccelomic  cavity  contains  the  omphalomesenteric  duct,  to 


30  THE    UMBILICUS    AND    ITS    DISEASES. 

which  a  loop  of  small  bowel  is  attached;  and  situated  in  the  lower  part  of  the  cord 
are  the  umbilical  arteries  and  the  allantois.  The  outer  part  of  the  cord,  even  at 
this  early  date,  shows  a  tendency  to  become  twisted. 

Examination  of  the  cord  in  an  embryo  12.5  mm.  long  (Fig.  9)  shows  an  exo- 
ccelomic  cavity  varying  considerably  in  diameter.  This  cavity  near  the  body  con- 
tains small  intestine  and  the  omphalomesenteric  artery  and  vein,  but  a  little  farther 
out  only  the  omphalomesenteric  duct  and  its  vessels.  The  remaining  portion  of 
the  cord  contains  the  umbilical  arteries,  the  umbilical  vein,  and  the  allantois.  The 
allantois  at  some  points  is  a  flaccid  tube,  but  at  other  points  shows  sac-like  dilata- 
tions.    It  finally  tapers  off  and  ends  in  a  point. 

In  the  embryo  18  mm.  long  (Fig.  10)  the  cord  near  the  umbilicus  is  distinctly 
enlarged.  This  enlargement  is  due  to  a  marked  dilatation  of  the  exoccelomic  cav- 
ity, which  contains  almost  all  the  bowel,  including  the  cecum  and  the  omphalo- 
mesenteric vessels.  A  section  farther  out  in  the  cord  shows  a  small  prolongation  of 
the  exoccelom,  containing  the  omphalomesenteric  vessels  and  cross-sections  of  the 
umbilical  arteries,  the  umbilical  vein,  and  the  allantois. 

A  longitudinal  section  of  the  cord  in  an  embryo  23  mm.  long  presents  an 
interesting  picture  (Fig.  11).  Near  the  embryo  the  upper  wall  of  the  cord  contains 
small,  cyst-like  spaces,  which  represent  areas  undergoing  organization.  The  exo- 
ccelomic cavity  is  large,  and  contains  nearly  all  the  small  bowel.  Passing  out 
between  the  coils  of  small  intestine  are  the  omphalomesenteric  artery  and  vein, 
which  are  continued  far  out  into  the  solid  portion  of  the  cord.  In  the  lower  wall  of 
the  cord  are  the  umbilical  arteries,  the  umbilical  vein,  and  the  allantois,  which  at 
some  points  is  solid  and  at  other  points  can  be  recognized  as  spindle-like  dilatations. 
At  this  stage  the  cord  shows  marked  twisting  in  its  outer  portion,  and  a  cross-section 
here  shows  the  umbilical  arteries  and  vein,  with  remnants  of  the  omphalomesenteric 
vessels  and  of  the  allantois. 

The  umbilical  cord  of  an  embryo  30  mm.  long  (Fig.  12)  shows  an  even  greater 
enlargement  near  the  embryo.  This  is  due  to  the  passive  increase  in  size  of  the 
exoccelomic  cavity,  which  now  contains  many  loops  of  small  bowel.  Passing  out 
between  these  loops  are  the  omphalomesenteric  vessels,  which  traverse  the  exo- 
ccelomic cavity,  and  continue  their  course  outward  in  a  narrow  chink  of  the  exo- 
ccelom. The  solid  portion  of  the  cord  is  small  in  comparison  with  the  exocce- 
lomic cavity.     It  contains  the  umbilical  arteries  and  vein,  as  well  as  the  allantois. 

By  the  time  the  embryo  reaches  45  mm.  in  length  (Figs.  13  and  14)  the  intestine 
has  usually  receded  into  the  abdomen.  The  exoccelomic  cavity  is  very  small,  and 
contains  only  the  omphalomesenteric  vessels.  A  cross-section  of  the  cord  near  the 
umbilicus  now  contains,  in  addition  to  the  umbilical  arteries  and  vein,  a  small 
chink  of  exoccelom  with  the  omphalomesenteric  vessels  in  its  interior,  and  the  allan- 
tois. The  allantois  varies  much  in  diameter:  in  some  places  it  is  a  solid  cord;  at 
other  points  it  shows  spindle-like  dilatations  (Fig.  13).  A  cross-section  of  an  em- 
bryo 5.2  cm.  in  length  presents  a  precisely  similar  picture.  In  Fig.  15  a  cross- 
section  of  the  omphalomesenteric  vein  is  seen  adherent  to  a  small  exoccelomic 
space. 

From  this  time  until  birth  the  cord  shows  only  a  few  minor  variations.  The 
relation  of  the  vein  to  the  arteries  naturally  varies  according  to  the  amount  of 
twisting  of  the  cord,  but  the  relation  of  the  allantois  to  the  arteries  is  constant.  It 
lies  between  and  slightly  below  the  arteries. 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION.  31 

Fig.  16  gives  a  cross-section  of  the  cord  in  an  embryo    6.5  cm.  long. 

Fig.  17  gives  a  cross-section  of  the  cord  in  an  embryo    7.5  cm.  long. 

Fig.  IS  gives  a  cross-section  of  the  cord  in  an  embryo    9.0  cm.  long. 

Fig.  19  gives  a  cross-section  of  the  cord  in  an  embryo  10.0  cm.  long. 

Fig.  20  gives  a  cross-section  of  the  cord  in  an  embryo  12.0  cm.  long. 

Fig.  21  gives  a  cross-section  of  the  cord  in  an  embryo  12.0  cm.  long. 

Fig.  22  gives  a  cross-section  of  the  cord  in  an  embryo  12.0  cm.  long. 

Fig.  23  gives  a  cross-section  of  the  cord  in  an  embryo  12.0  cm.  long. 

Fig.  24  gives  a  cross-section  of  the  cord  in  an  embryo  15.0  cm.  long. 
In  embryos  12  cm.  in  length  the  patent  allantois  may  be  detected  in  the  cord  at 
a  considerable  distance  from  the  fetus  (Fig.  22).     Remnants  of  the  omphalo- 
mesenteric duct  in  the  cord,  as  seen  in  Fig.  21,  are  very  rare. 


THE  OMPHALOMESENTERIC  DUCT. 

In  the  very  early  embryo  the  yolk-sac  is  intimately  attached  to  its  ventral 
surface  (Fig.  1),  and  in  a  short  time  extends  into  the  embryo,  forming  the  fore-gut 
and  the  hind-gut  (Fig.  2).  The  amnion  rapidly  encompasses  the  embryo,  and 
pushes  the  yolk-sac  away.  Inasmuch  as  part  of  the  yolk-sac  already  forms  the 
digestive  tract,  it  is  firmly  anchored  to  the  embryo.  The  rest  of  the  yolk-sac  still 
retains  its  connection  with  the  digestive  tract  by  a  drawn-out  and  narrow  portion, 
which  is  called  the  omphalomesenteric  or  vitelline  duct  (Fig.  3).  The  yolk-sac 
proper,  the  omphalomesenteric  duct,  and  the  primitive  digestive  tract,  at  this 
stage,  form  various  portions  of  one  and  the  same  cavity.  The  omphalomesenteric 
duct  can  be  recognized  in  the  embryo  2.5  mm.  long.  It  will  be  noted  in  Fig.  3  that 
the  omphalomesenteric  du-ct  is  surrounded  on  all  sides  by  exoccelom;  in  other 
words,  it  lies  in  the  exoccelomic  cavity. 

In  an  embryo  5  mm.  in  length  (Fig.  5)  the  first  loop  of  small  bowel  is  seen,  and 
passing  off  from  its  convexity  is  the  omphalomesenteric  or  vitelline  duct.  This 
duct,  accompanied  by  the  omphalomesenteric  artery  and  vein,  passes  outward  in 
the  exoccelomic  cavity  of  the  cord,  and  emerging  from  the  amniotic  sac  reaches 
the  yolk-sac. 

When  the  embryo  reaches  7  mm.  in  length  (Fig.  6)  a  loop  of  small  bowel  can  be 
seen  in  the  exoccelomic  cavity  of  the  cord,  and  projecting  from  its  convex  surface 
the  patent  omphalomesenteric  duct.  Accompanying  the  duct  are  the  omphalo- 
mesenteric artery  and  vein. 

In  another  embryo  of  the  same  length  (Fig.  7)  we  note  that  the  duct  has  already 
lost  its  connection  with  the  small  bowel.  Beyond  this  point,  however,  it  is  patent 
and  appears  as  a  bulbous  dilatation  in  the  cord  a  short  distance  from  the  embryo. 
Hence  it  is  evident  that  variations  may  exist  and  that  the  duct  may  or  may  not  still 
be  connected  with  the  small  bowel  when  the  embryo  is  7  mm.  long. 

A  study  of  Fig.  8,  from  an  embryo  10  mm.  in  length,  shows  that  the  first  loop  of 
small  bowel  extends  far  outward  in  the  exoccelomic  cavity  of  the  cord.  It  is 
accompanied  by  the  omphalomesenteric  vessels,  which  are  continued  out  into  the 
cord  for  the  entire  length,  terminating  in  the  yolk-sac.  The  duct  accompanies  the 
vessels  as  far  as  the  yolk-sac. 

In  Fig.  9,  from  an  embryo  12.5  mm.  long,  the  omphalomesenteric  duct  is  patent 
in  the  exoccelom,  and  apparently  still  communicates  with  the  small  bowel.     The 


32 


THE    UMBILICUS    AND    ITS    DISEASES. 


duct  is  lined  with  one  layer  of  low  cuboid  epithelium.  The  patent  portion  can  be 
traced  outward  in  the  cord;  it  forms  a  bulbous  dilatation  near  the  yolk-sac,  into 
which  it  opens.     The  yolk-sac  also  is  lined  with  one  layer  of  cuboid  epithelium. 

In  the  embryo  of  18  mm.  (Fig.  10)  all  trace  of  the  omphalomesenteric  duct  is 
lost,  but  its  vessels  are  still  found  in  the  cord.     They  lie  in  a  funnel-shaped  pro- 


Sup.  mes  a 


Omphmes  vess. 


Fig.  33. — A  Diagrammatic  Representation  of  the  Umbilical  Region  of  a  Fetus  at  Term. 
An  exceptional  feature  of  the  picture  is  the  persistence  of  the  omphalomesenteric  structures  in  the  form  of  a  well- 
defined  vascular  Meckel's  diverticulum.  Note  the  relationship  between  the  omphalomesenteric  vessels,  the  superior 
mesenteric  artery,  and  the  portal  vein.  In  the  cord  the  vitelline  vessels  still  persist  in  the  organized  exoccelom.  At 
birth  all  trace  of  the  omphalomesenteric  structure  has  usually  disappeared,  but  the  allantoic  cord  often  persists,  and  is 
seen  between  and  below  the  umbilical  arteries.  It  is  continuous  with  the  urachus,  which  may  have  a  number  of  spindle- 
shaped  dilatations  down  to  the  bladder.     These  may  or  may  not  have  lumina. 


longation  of  the  exoccelom.  These  vessels  can  be  easily  followed  in  Figs.  11,  12, 
13,  14,  and  20.  Generally  speaking,  the  omphalomesenteric  duct  usually  disappears 
when  the  embryo  is  between  4  and  12  mm.  in  length,  but  its  vessels  persist  long  after 
the  duct  has  disappeared. 

In  the  earliest  stages  the  omphalomesenteric  arteries  are  two  in  number;  they 


EMBRYOLOGY    OF    THE    UMBILICAL    REGION.  33 

pass  out  on  each  side  of  the  yolk-sac.  They  arise  from  a  plexus  of  from  two  to  four 
smaller  vessels  directly  from  the  aorta.  The  left  artery  disappears,  the  right  per- 
sists, follows  the  omphalomesenteric  duct,  and  terminates  in  a  network  over  the 
entire  yolk-sac  (Figs.  2,  4,  and  5).  The  proximal  portion  of  the  omphalomesenteric 
artery  later  becomes  converted  into  the  superior  mesenteric  artery. 

In  the  beginning  the  omphalomesenteric  veins  are  two  in  number.  The  right 
disappears;  the  left  collects  the  blood  from  the  entire  yolk-sac  and  from  the 
omphalomesenteric  duct,  and  in  the  liver  anastomoses  with  the  left  umbilical 
vein.  Before  entering  the  liver  it  receives  tributaries  from  the  intestine  (vena 
mesenterica  superior,  Fig.  7).     It  later  forms  the  portal  vein. 

In  Fig.  14,  from  an  embryo  4.5  cm.  long,  the  omphalomesenteric  duct  still  per- 
sists as  a  cord  passing  from  the  intestine  to  the  abdominal  wall.  It  consists  of 
embryonic  connective  tissue  and  has  an  epithelial  center,  but  no  lumen. 

Fig.  23  is  a  cross-section  of  the  umbilical  cord  near  the  abdominal  wall  of  an 
embryo  12  cm.  long.  The  omphalomesenteric  duct  is  recognized  as  a  solid  epithelial 
cord.     Its  blood-vessels  are  still  patent. 

Although  the  duct  usually  disappears  early  in  the  embryologic  development,  it 
is  occasionally  found  patent  at  birth.  In  other  cases  only  a  portion  of  the  duct 
remains.  When  the  duct  remains  patent,  an  umbilical 
fecal  fistula  develops  as  soon  as  the  cord  comes  away. 
If  the  inner  end  be  patent,  we  have  a  Meckel's  diverticulum  (Fig.  26).  This 
may  or  may  not  be  adherent  to  the  umbilicus  (Fig.  25).  In  rare  instances  the 
duct  is  obliterated  both  at  the  intestine  and  at  the  umbilicus,  but  the  median  por- 
tion persists.  In  such  a  case  we  have  an  intestinal  cyst.  In  a  few  cases 
remnants  of  the  duct  haye  been  detected  in  the  umbilical  region  between  the 
peritoneum  and  the  abdominal  walL  One  of  the  most  frequent  sites  for  remains 
of  the  duct  is  at  the  point  of  attachment  of  the  umbilical  cord.  In  such  cases, 
when  the  cord  comes  away,  a  small,  raspberry-like  mass  will  be  noted  at  the 
navel.  Occasionally  the  omphalomesenteric  vessels  may  still  persist  as  imper- 
vious fibrous  cords  (Fig.  21).  These  have  in  some  instances  given  rise  to  intes- 
tinal obstruction.  All  these  conditions  which  produce  definite  clinical  entities 
will  be  discussed  fully  in  subsequent  chapters. 


LITERATURE  CONSULTED  ON  EMBRYOLOGY  OF  THE  UMBILICAL  REGION. 

Ahlfeld,  Fr. :  Die  Allantois  des  Menschen  und  ihr  Verhaltnis  zur  Nabelschnur.     Arch,  f .  Gynak., 

1876,  x,  81. 
Cazin,  Henry:    Etude  anatomique  et  pathologique  sur  les  diverticules  de  l'intestin.     These  de 

Paris,  1862,  No.  138. 
Freer,  James  A.:  Abnormalities  of  the  Urachus.     Ann.  of  Surg.,  1887,  v,  107. 
Ledderhose,  G.:  Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Lowy,  H:  Die  Riickbildung  der  Allantois  beim  Menschen.     Arch,  fiir  Anat.  und  Physiologie, 

Anat,  Abth.,  1905,  159-176. 
Meyer,  Arthur:    On  the  Structure  of  the  Human  Umbilical  Vesicle.     Amer.  Jour.  Anat.,  1904, 

iii,  155. 
Monod,  J.:    Des  fistules  urinaires   ombilicales   dues  a  la  persistance  de  l'ouraque.     These  de 

Paris,  1899,  No.  62. 
Vaughan,  George  T.:    Patent  Urachus.     Review  of  the  cases  reported.     Operation  on  a  case 

complicated  with  stones  in  the  kidneys.     A  note  on  tumors  and  cysts  of  the  urachus.     Trans. 

Amer.  Surg.  Assoc,  1905,  xxiii,  273. 
Mall,  Franklin  P.:  Jour.  Morphology,  1891,  v,  459-477. 
4 


CHAPTER  II. 
THE  ANATOMY  OF  THE  UMBILICAL  REGION. 

The  appearance  of  the  umbilicus  from  without. 

Personal  clinical  studies  of  the  various  forms  of  the  umbilicus. 

The  umbilicus  as  viewed  from  its  peritoneal  side. 

Varieties  of  the  fibrous  ring. 

Disposition  of  the  vessels. 

Peri-umbilical  veins. 

Varieties  of  umbilical  fascia. 

Elevation  of  the  peritoneum  in  the  form  of  a  mesentery. 

Peritoneal  fringes  containing  fat. 

Diverticula. 

Clinical  examples  of  defects  of  the  abdominal  wall. 

Relation  of  the  outside  of  the  umbilicus  to  the  peritoneal  side. 

The  umbilicus  in  animals. 

The  lymphatics  of  the  umbilical  region. 

The  sensory  nerve-supply  of  the  umbilicus. 

The  skin  umbilicus. 

The  amniotic  umbilicus. 

Absence  of  the  umbilicus. 

The  umbilicus  during  pregnancy. 

Kuster,  in  1874,  in  his  paper,  "New  Growths  of  the  Umbilicus  in  the  Adult 
and  Their  Operative  Treatment,"  briefly  refers  to  the  anatomy  of  the  umbilical 
region. 

He  enumerates  the  layers  of  the  abdominal  wall  in  the  region  of  the  umbilicus 
as  follows : 

1.  The  skin. 

2.  The  superficial  fascia  and  more  or  less  fat. 

3.  The  superficial  sheath  of  the  abdominal  muscle. 

4.  The  rectus  abdominalis. 

5.  The  deep  layer  of  the  sheath. 

6.  The  subperitoneal  connective  tissue. 

7.  The  peritoneum. 

In  the  mid-line  of  the  abdomen  layers  3-5  are  replaced  by  a  thick  cord  of 
connective  tissue,  forming  the  linea  alba,  which,  at  the  umbilicus,  may  reach  1  cm. 
in  breadth. 

The  umbilical  scar  contains  four  fetal  structures:  (1)  the  umbilical  vein,  which 
passes  to  the  liver  along  the  suspensory  ligament;  (2)  and  (3),  the  umbilical 
arteries,  passing  downward  and  outward  to  the  bladder;  (4)  the  urachus,  which 
passes  to  the  bladder. 

THE  APPEARANCE  OF  THE  UMBILICUS. 
Catteau  in  his  thesis,  in  1876,  on  the  Umbilicus  and  its  Modifications  in  cases 
of  Abdominal  Distention,  refers  in  some  detail  to  the  appearance  of  this  region. 

34 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 


35 


Fu-rro 


Umbilical 
cicatrix 


Ma-melon 


According  to  this  author,  the  typical  umbilicus  presents  a  circular  cushion  or  base, 
which  forms  the  elevated  outer  margin  of  an  area  showing  a  hollow,  from  the  bottom 
of  which  arises  an  elevation  which  Catteau 
calls  the  m  a  m  e  1  o  n  .  Situated  in  or  near 
this  elevation  is  the  umbilical  scar.  Between 
the  mamelon  and  the  umbilical  cushion  is  a 
definite  furrow.  Fig.  34  shows  roughly  the 
component  parts  of  Catteau's  typical  umbili- 
cus. 

Probably  the  most  thorough  study  of  the 
subject  was  made  by  Bert  andViannay,  who, 
in  over  one  hundred  cases,  made  molds  of  the 
umbilicus.  The  following  is  taken  from  some 
of  the  more  important  portions  of  their  article : 
The  umbilicus  is  a  depression  in  the  skin,  at 
the  bottom  of  which  is  concealed  the  cicatrix 
left  by  the  throwing  off  of  the  cord.  This  cica- 
trix is  drawn  inward  by  the  retraction  of  the 
umbilical  vessels  and  of  the  special  tissue  which 
surrounds  them  (Wharton's  jelly).  Bert  and 
Viannay  set  out  to  study  more  especially  the 
morphology  of  the  outside  of  the  umbilicus, 
inasmuch  as  investigations  bearing  upon  this 
special  point  up  to  that  time  had  been  lacking. 
They  claimed  that  their  method  was  superior 
to  that  employed  by  Catteau,  who  had  relied 
on  sketches  made  at  the  bedside  of  the  patient, 
which  lack  both  the  exactness  and  the  fidelity 
of  molds.  Their  work  was  based  on  the  com- 
parative study  of  112  models  made  in  different 
hospitals,  from  individuals  whose  ages  varied 
from  two  and  one-half  to  seventy-seven  years. 
More  than  half  of  the  patients  were  males. 
They  were  taken  as  they  came,  without  being 
selected,  except  that  none  presenting  a  patho- 
logic umbilicus,  distended  by  an  intraperitoneal 
effusion  or  by  a  hernial  sac,  was  included. 

The  examination  of  the  molds  at  once  im- 
pressed these  observers  with  the  fact  that  the 
form  of  the  umbilicus  presents  a  great  vari- 
ability, rendering  a  definite  classification  some- 
what difficult.  Nevertheless,  a  certain  num- 
ber of  types  can  be  distinguished.  In  one  the 
umbilicus  has  its  longest  diameter  directed 
transversely — t  he  transverse  um- 
bilicus. In  another,  on  the  contrary, 
vertical  umbilicus.  Furthermore,  in  a  third  type — t  he  round 
umbilicus  —  the  vertical  and  transverse  diameters  are  more  or  less  equal. 


Fig.  34. — -Normal  Umbilicus  According  to 
Catteau. 

A  represents  the  scheme  of  the  normal 
umbilicus  as  described  by  Catteau.  This  so- 
called  typical  umbilicus  consists  of  a  cushion 
and  a  central  depression,  in  the  bottom  of  which 
are  two  structures — -a  mamelon  which  is  more 
or  less  prominent,  and  the  umbilical  cicatrix. 
The  mamelon  must  be  regarded  as  the  remains 
of  the  solid  lower  part  of  the  fetal  cord  which 
contained  the  umbilical  arteries  and  urachus 
(allantoic  stalk;.  The  cicatrix,  on  the  other 
hand,  seems  to  be  due  to  the  puckering  of  the 
skin  over  the  region  where  the  exocoslomic  fun- 
nel has  left  the  embryo.  The  mamelon  is  said 
to  lie,  as  a  rule,  to  the  left  of  the  umbilical 
cicatrix,  as  indicated  here.  We  have,  however, 
observed  the  reverse.  (See  Plate  II,  No.  22.) 
The  projection  of  the  mamelon  from  the  umbil- 
ical depression  naturally  gives  rise  to  a  sur- 
rounding furrow. 

B  illustrates  the  only  example  of  this  type 
that  we  have  encountered  in  about  200  cases, 
and  consequently  our  findings  do  not  sub- 
stantiate the  claims  of  Catteau. 


the  prominence   is  vertical — t  h  e 


36  THE    UMBILICUS    AND    ITS    DISEASES. 

Between  these  three  main  types  can  be  found  a  large  variety  of  intermediary  forms. 
Sometimes,  even  after  careful  examination,  one  would  hesitate  to  determine  to 
which  class  a  given  umbilicus  belongs. 

Bert  and  Viannay's  figures  are  as  follows.     Instances  of — 

1.  Transverse  umbilicus 71  cases 

2.  Round  umbilicus 29     " 

3.  Vertical  umbilicus 12     " 

They  examined  systematically  the  umbilical  cicatrix  in  all  patients  coming 
under  their  care.  They  regard  the  umbilicus  as  a  cutaneous  depression, — a  sort 
of  retracted  cone, — in  which  one  is  able  to  distinguish  the  base,  open  in  front  and 
continuous  with  the  skin  of  the  abdomen.  The  bottom,  or  the  summit,  according 
to  the  point  of  view,  is  adherent,  and  is  formed  by  the  umbilical  cicatrix  and  the 
surrounding  parts. 

They  also  drew  attention  to  the  fact  that  Catteau  had  spoken  of  four  constituent 
elements — a  cutaneous  cushion  or  collar,  which  corresponded  to  their  base;  an 
elevation  or  mamelon,  which  corresponded  to  their  bottom  and  which  carried  the 
cicatrix;  and,  finally,  a  furrow  or  groove.  They  pointed  out  that  the  four  elements 
are  present  in  an  occasional  umbilicus,  which  they  would  then  speak  of  as  t  h  e 
complete  umbilicus,  but  that  this  complete  umbilicus  is  met  with  in  less 
than  half  of  the  cases.  For  example,  in  112  molds  Bert  and  Viannay  found  the 
umbilicus  34  times  devoid  of  a  central  mamelon,  and  21  times  without  a  surrounding 
cushion,  but  as  the  cushion  and  the  mamelon,  or  teat-like  elevation,  are  divided  by 
the  furrow,  when  one  of  the  two  elements  or  when  both  are  absent,  the  depression 
is  also  absent.  The  absence  of  one  or  more  of  these  constituents  of  the  umbilicus 
creates  multiple  combinations,  which  are  capable  of  producing  a  certain  number  of 
types — a  type  of  umbilicus  without  cushion  or  mamelon,  a  type  with  cushion  and 
without  mamelon,  a  type  without  cushion  but  with  mamelon,  and  so  on. 

The  base,  cushion,  or  umbilical  hollow  is  open  in  front  and 
continuous  with  the  skin  of  the  abdomen  in  something  like  18.75  per  cent  of  the 
cases.  When  the  surrounding  skin  inclines  gradually  toward  the  umbilical  depres- 
sion by  a  gentle  slope,  no  prominence  can  be  distinguished.  In  such  cases 
we  are  dealing  with  an  umbilicus  without  cushion.  More  frequently  the  base  of 
the  umbilical  depression  is  surrounded  by  a  circular  elevation,  a  veritable  cutaneous 
cushion.  In  about  6  per  cent  of  the  cases  this  cushion  is  complete  and  forms  a 
uniform  elevation,  completely  surrounding  the  cutaneous  orifice  of  the  umbilical 
depression.  Ordinarily  it  is  incomplete  and  occupies  only  a  portion  of  the  circum- 
ference of  the  umbilicus;  for  example,  half  of  the  circumference,  the  superior  or 
inferior,  or  one  of  its  lateral  walls.  This  cushion  then  takes  the  form  of  a  half- 
moon,  a  crescent,  etc.,  and  gives  rise  to  numerous  varieties  in  the  appearance  of  the 
umbilicus. 

The  bottom  of  the  umbilical  depression,  despite  Catteau's 
description,  is  not  always  occupied  by  an  eminence  carrying  the  cicatrix. 

(a)  A  smooth  depression.  In  34  cases  Bert  and  Viannay  found  the 
bottom  absolutely  smooth,  without  any  trace  of  elevation  or  mamelon.  In  these 
cases  the  umbilical  depression  was  also  regular  and  infundibular  in  form.  They 
observed  two  varieties :  In  the  first  the  umbilical  orifice  may  be  large,  widely  open, 
presenting  at  its  extreme  bottom  the  cicatrix,  smooth  or  depressed,  and  having  a 


THE    ANATOMY    OF    THE    UMBILICAL    REGION.  37 

stellar  or  linear  aspect;  in  the  second  the  opening  is  narrow,  and  one  has  to  separate 
the  folds  in  order  to  see  the  cicatrix  which  occupies  the  bottom  of  the  depression. 

(b)  T  h  e  mamclon  or  elevation.  In  about  two-thirds  of  the  cases 
the  bottom  of  the  umbilical  depression  is  occupied  by  an  eminence  or  mamelon. 
The  form  of  the  eminence  shows  an  infinite  variation:  sometimes — and  this  is  the 
rule — it  is  single,  sometimes  double,  occasionally  triple.  When  the  mamelon 
is  double,  the  two  elevations  may  be  juxtaposed,  so  that  a  vertical  or  median 
depression  separates  them.  When  superimposed,  the  superior  elevation  is  separated 
from  the  inferior  by  a  small  transverse  depression.  Usually,  however,  when 
the  mamelon  exists,  it  is  single. 

(c)The  umbilical  cicatrix  occupies  the  bottom  of  the  umbilical 
depression  when  the  latter  is  smooth.  In  the  umbilicus  with  a  mamelon  in  the 
depression  it  occupies  sometimes  the  central  point;  at  other  times  it  is  on  one  side 
of  the  mamelon.  The  cicatrix  may  be  punctiform  and  hardly  visible;  at  other 
times  it  is  linear  and  branches  in  different  directions.  It  may  be  vertical  or  more 
frequently  transverse.  Sometimes  it  has  a  stellar  arrangement  with  a  variable 
number  of  branches. 

(d)  The  w  a  1 1  s  of  the  umbilical  depression  may  present  as  many  variations 
as  the  other  elements  constituting  the  umbilicus.  These  variations  are  chiefly 
dependent  on  the  depth  of  the  umbilical  depression,  which  itself  depends  upon  the 
degree  of  development  of  the  subcutaneous  adipose  tissue.  Hence  we  find  an 
explanation  of  the  fact  that  a  deep  umbilicus  is  more  frequent  in  women  and  in 
stout  people.  On  the  other  hand,  young  infants,  old  men,  and  cachectic  patients 
have  an  umbilicus  less  deep,  or  even  on  a  level  with  the  skin.  In  the  deep  umbili- 
cus the  walls  are  sometimes  absolutely  smooth.  Sometimes  the  depression  is 
occupied  by  a  cutaneous  elevation  uniting  the  cushion  and  mamelon,  a  condition 
analogous  to  that  found  in  the  case  of  the  muscular  pillars  which  hold  up  the 
walls  of  the  ventricle  of  the  heart. 

The  umbilical  cavity  varies  in  size  and  in  form.  It  can  readily  be 
understood  that  the  degree  of  depth  of  the  umbilical  depression,  the  presence  or  ab- 
sence of  the  central  mamelon,  and  the  larger  or  smaller  opening  at  the  base  of  the 
skin,  will  modify  entirely  the  form  and  dimensions  of  the  cavity  of  the  umbilicus. 
From  this  point  of  view  the  examination  of  their  plaster  molds  is  very  instructive. 
They  show  that  the  axis  of  the  umbilical  opening  is  rarely  perpendicular  to  its  base. 
Instead  of  passing  directly  into  the  depth,  it  deviates  sometimes  upward,  sometimes 
downward,  sometimes  laterally.  Moreover,  the  solid  cone  of  the  plaster  mold, 
representing  the  cavity  of  the  umbilical  depression,  is  always  more  or  less  incurved. 
Sometimes  it  is  turned  out  in  a  fantastic  fashion.  In  their  series  of  molds,  in  addi- 
tion to  the  transverse,  the  round,  and  the  vertical  umbilicus,  with  or  without  cush- 
ion, with  or  without  mamelon,  they  encountered  several  odd  forms — for  example, 
the  funnel-shaped  umbilicus,  those  suggesting  the  mouth  of  a  furnace,  the  snout  of 
a  fish,  and  others. 


PERSONAL  CLINICAL  STUDIES  OF  THE  VARIOUS  FORMS  OF  THE  UMBILICUS. 
Together  with  Mr.  Brodel  I  visited  the  various  wards  of  the  Johns  Hopkins 
Hospital  and  examined  the  umbilicus  of  nearly  all  the  patients,  males  and  females, 
young  and  old,  white  and  black,  including  quite  a  number  of  pregnant  patients. 


38  THE    UMBILICUS    AND    ITS    DISEASES. 

Thus  in  the  large  group  of  pictures  presented  we  have  a  rather  comprehensive  idea 
of  the  various  forms  the  umbilicus  may  assume  under  normal  conditions.  With  the 
examination  of  many  thousands  of  people  doubtless  other  forms  will  be  detected, 
but  the  pictures  here  presented  serve  to  show  the  forms  usually  met  with. 

The  60  drawings  of  normal  umbilici  arranged  on  Plates  I-TV  were  made  in  the 
wards  with  the  patients  in  bed.  This  insured  uniformity  of  posture,  and  eliminated 
accidental  skin-folds,  such  as  always  appear  when  the  body  is  in  flexion  or  in 
hyperextension.  These  plates  show  that  it  is  difficult  to  speak  of  a  definite  and 
uniform  topography  of  this  region.  The  variations  are  exceedingly  numerous,  and 
include  a  large  number  of  the  most  bizarre  forms.  The  following  are  attempts  to 
roughly  classify  the  cases  into  groups  : 

Group  I. — Cushion  incomplete;  presents  a  crescent  or  horseshoe  fold  below 
the  umbilicus  (Figs.  1-7).  This  condition  suggests  a  taut  urachus  and  lateral 
umbilical  ligaments  pulling  the  navel  downward. 

Group  II.  —  Cushion  incomplete,  but  found  above  the  umbilicus.  This  is 
the  reverse  of  what  is  present  in  Group  I  (Figs.  8-12).  This  condition  suggests 
the  presence  of  a  taut  and  short  round  ligament  of  the  liver  coexisting  with  relaxa- 
tion of  the  abdominal  wall.  The  most  pronounced  cases  of  this  type  seem  to  be 
found  in  women  who  have  had  many  children. 

Group  III.  —  Funnel-shaped  umbilicus  (Figs.  13-19).  The  cushion  has 
been  padded  with  adipose  tissue.  At  the  bottom  of  the  funnel  the  umbilical  scar 
is  found.  The  mamelon  is  absent.  A  deep  funnel  has  a  narrow  apex  (Fig.  14). 
A  shallow  funnel,  on  the  other  hand,  possesses  a  broad  bottom  (Fig.  16).  The 
cicatrix  may  be  large  (Fig.  16)  or  small  (Fig.  19),  central  (Fig.  19)  or  peripheral 
(Fig.  18). 

Group  IV.  —  The  horizontal  oval  umbilicus.  A  cushion  completely  sur- 
rounds a  well-marked  mamelon  and  an  umbilical  cicatrix  (Figs.  20-24).  This  is 
the  group  which  most  nearly  coincides  with  Catteau's  scheme  of  the  normal 
navel. 

G  r  o  u  p  V  .  —  The  horizontal,  slit-like  umbilicus,  short  or  long,  occurs  in  both 
sexes.  It  should  be  remembered  that  almost  every  type  of  navel  can  be  made  to 
appear  as  a  horizontal  slit  by  bending  the  body  sharply  forward.  In  the  three  cases, 
Figs.  25-27,  the  appearances  are  not  due  to  this  factor,  but  represent  the  abdomen 
at  rest  with  the  individual  in  the  recumbent  posture. 

Group  VI.  —  The  triangular,  slit-like  umbilicus  resembling  the  letter  T 
(Figs.  28,  29,  31),  or  horizontal,  like  an  H  viewed  from  the  side  (Fig.  30). 

Group  VII.- —  The  perpendicular,  slit-like  umbilicus  (Figs.  32-35).  This 
form  suggests  a  closer  approach  of  the  two  recti  muscles,  with  a  consequent  increased 
efficiency  against  intra-abdominal  pressure. 

Group  VIII.  —  The  perpendicular  oval  umbilicus  (Figs.  36-41).  Cushion 
and  mamelon  and  scar  are  arranged  as  in  Group  IV  (Figs.  20-24),  with  the  usual 
range  of  variations. 

Group  IX.  —  The  prominent,  button-like  umbilicus  (Figs.  42-60).  The 
button  may  be  round  (Fig.  42),  oval  (Fig.  45),  or  spiral  (Figs.  54  and  55),  usually 
with  a  central  horizontal,  scar-like  furrow.  A  crescent-shaped  pit  may  be  found 
under  the  button  (Figs.  49,  50,  and  59).  The  button  may  have  a  cushion  as  a  collar 
(Fig.  42)  or  be  without  one  (Figs.  44  and  48).  In  pregnancy  the  button  form  may 
be  simulated  by  a  small  hernial  protrusion  (Fig.  60).     (See  also  Plate  VI,  p.  467.) 


THE   ANATOMY   OF   THE   UMBILICAL   REGION.  39 

A  few  general  facts  worthy  of  note  are  as  follows : 

(1)  The  navel  in  the  colored  race  is  usually  larger  than  that  in  the  white  race. 
This  may  be  due  to  the  fact  that  the  negro's  skin  is  thicker  than  that  of  the  white, 
or  possibly  to  the  lack  of  proper  medical  attention  during  labor,  resulting  in  a  larger 
scar.     Compare— 

White  Colored 

Fig.    6  with  Fig.    7 

"     19                                 "  "     16 

"     54                                 "  "     55 

"     58                                 "  "     56 

(2)  The  umbilicus  in  the  infant  is  much  larger  in  proportion  to  the  body  weight 
than  is  that  of  the  adult.     Compare — 

(3)  There  is  no  definite  relation  between  the  size  of  the  adult  and  the  size  of  the 
umbilicus.     A  small  person  may  have  a  large  umbilicus,  and  vice  versa. 

(4)  In  the  adult  the  depressed  umbilicus  is  far  more  frequent  than  the  elevated 
or  button-shaped  type. 

(5)  The  button  is  the  infantile  form. 

(6)  A  large  umbilicus  of  the  horizontal  type  is  associated  with  a  wide  linea  alba, 
also  with  diastasis  of  the  recti  abdominis  muscles.  Diastasis  of  the  recti  is  especially 
pronounced  in  infants  and  children.  It  is  also  found  at  the  end  of  pregnancy 
(Fig.  60),  when  it  may  lead  to  the  formation  of  a  small  hernia.  (See  also  Plate  VI, 
p.  467.) 

(7)  The  linea  nigra  in  a  multipara  may  be  in  the  mid-line  (Figs.  24,  31,  and  40), 
or  bilaterally  displaced  at  the  umbilicus,  as  in  Figs.  21  and  60. 

(8)  The  umbilicus  of^  a  multipara  is,  as  a  rule,  more  wrinkled,  and  the  peri- 
umbilical skin  more  relaxed  in  character  than  in  a  nullipara  (Figs.  9,  29,  30,  37, 
and  40). 

(9)  Except  for  the  growth  of  hair  around  the  navel  in  the  adult  male,  there  are 
no  sexual  differences  between  it  and  the  navel  in  a  nullipara.  (In  these  drawings, 
in  order  to  insure  clearness  of  form,  the  hair  has  been  omitted.) 

(10)  Obesity  has  a  tendency  to  produce  the  funnel-shaped  umbilicus  (Figs.  12, 
14,  and  19). 


HISTOLOGIC  APPEARANCE  OF  THE  UMBILICUS. 
As  pointed  out  by  Hertz  and  others,  the  umbilical  pit  is  at  first  covered  over 
with  squamous  epithelium,  but  is  devoid  of  papillae.  Later  the  epithelium  is  identi- 
cal with  that  of  the  outer  skin.  The  scar,  however,  is  usually  lacking  in  sebaceous 
or  sweat-glands.  According  to  Hertz,  Pernice  was  able  to  detect  in  three  infants 
remnants  of  the  omphalomesenteric  duct  in  the  scar,  it  being  recognized  as  a  canal 
lined  with  cylindric  epithelium. 


THE  UMBILICUS  AS  VIEWED  FROM  ITS  PERITONEAL  SIDE. 

The  most  important  articles  bearing  on  this  subject  are  those  of  Gauderon 
(1876)  and  of  Levadoux  (1907). 

As  was  pointed  out  in  the  chapter  on  the  Embryology  of  the  Umbilical  Region, 
the  umbilical  arteries,  the  urachus,  one  or  both  umbilical  veins,  and  the  omphalo- 


40 


THE    UMBILICUS    AND    ITS    DISEASES. 
PLATE  I. 


■Female,  age 33  ,  120  lbs.  Opara. 


Female,  age  38.  116  lbs.  I  para 

(Female,  agfc58,  22.8lbs.  5  para 


1Male,a5e30.    1^8  lbs 


&  13 

Female,  age  58  .  120  Ibs.'Tpara      Female,  age36,  105  lbs.  Opara 


4-  ,9  \h 

Female,  age  33,llSLk>vifpara|    [Female,  age  60.  120  lbs.  lOpara     Male,  age  ^6  ,   178  lbs. 


to 


Femak,  age  50,  110  lbs.  Opara      Male,   age  39  .    130  lbs. 


15 

Fein  a 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 

PLATE   II. 


41 


Female,  age22,  l'30  Ibs.Opara        Female ,  agel9 ,  1^5  lbs.  I  para 


26 

Male,  age  58.   I3&  lbs. 


Female,  age 23,  HZ  lbs.  Opara       .22 

Male,  age  19.  120  lbs 


27 

Male,   age  4-2,      125  lbs. 


18 


Female,  age ¥2  ,  '39  lbs.  3  para 


19 

Male,  age  63,    186  lbs 


Female  ,  age.38.  IZ5  lbs. 3 para       Female,  age  45,  100  Ibs.Opara  , 


20 

Male.age^,    IOT  lbs 


idle  ,  age  79.  35  lbs.  Opara        Female ,  age  Vf,  135  lbs.  3  para 


42 


THE    UMBILICUS    AND    ITS    DISEASES. 
PLATE  III. 


31  36  4I 

Female,  age  19.  149  lbs.  7  para         Female  .  age  66,  125  lbs.  2 para        Female,  age  18  ,  130  lbs.  I  para 


32 


42 


Female,  age  14  150  lbs.  3  para      Female  ,  age  32.  ,  HO  lbs.  6  para      Female,  age  28  ,  99  lbs  .  2  pare 

.  ■ 


38 

Female,  age  18,  110  lbs     0  para  aq 

Male,  6  months    9  lbs 


35 

Male,    age  39     150  lbs 


40  45 

Female,  age  3&,  128  lbs.  4  para       Female,    1  '/l  month  b   5  lbs. 


THE    ANATOMY    OF   THE    UMBILICAL   REGION. 

PLATE  IV. 


43 


lbs.  — —  mmam 

Female,  age  15  ,  90  lbs.,  0  para        Male  ,  ag<?  1%  year  j,    16  lbs. 


47 


Xi 


Mate  ,  6  years  ,    43  lbs. 


Female,  age47,  101  lbs,  Opara     &&& 

Female  .  age  6  ,  45  Lbs. 


F 


*8 

Female,    13  days    &  lbs. 


Male,  age  3h  ,  30  lbs.  58 


Male,   age  36,     120  lbs. 


>> 


54 


49  _      Male,  age  44.     130  lbs- 

Female,  age  51  f  100  lbs,  II  paro 


50 


59 

Male,   2>monVKs,  H'/l  lbs. 


Female,  age  4r  40  lbs . 


60  /  [*M 

Female,  age 20,  116  lbs,    I  para       Female,  age 21 .  H5  lbs.  pregnant 


44 


THE    UMBILICUS   AND    ITS   DISEASES. 


Fig.  35.-«~A  Type  of  Umbilical  Region  in  the  Adult,  Viewed 
FROM  Within.  (Half  nat.  size.) 
Within  the  umbilical  ring  is  seen  a  small,  shallow  pit  with  strong 
resistant  walla  and  base.  There  is  no  mesentery  of  the  obliterated 
hypogastric  arteries  or  of  the  urachus,  excepting  perhaps  in  their 
pelvic  portion.  They  are,  nevertheless,  clearly  seen  throughout  their 
entire  extent.  The  'triangular  falciform  ligament  is  very  short,  and 
the  round  ligament  of  the  liver  becomes  lost  in  the  abdominal  wall 
at  least  S  cm.  above  the  umbilicus.     (Personal  observation.) 


Fig.  36. — A  Frequent  Type  of  the  Umbilical 
Region  in  the  Adult,  Viewed  from  Within. 
(Half  nat.  size.) 

The  umbilical  ring  is  covered  with  radiating  bun- 
dles of  fascia  through  which  the  position  of  the  ring 
can  still  be  seen.  The  urachus  and  obliterated  hypo- 
gastric vessels  are  not  clearly  defined  in  their  upper 
portion,  but  appear  to  be  lost  in  a  broad,  flat  band- 
As  the  two  arrows  show,  there  is  a  shallow  recess  be. 
hind  this  band  on  each  side.  The  round  ligament  of 
the  liver  shows  the  same  arrangement  as  in  the  pre- 
ceding figure.      (Personal  observation.) 


THE    ANATOMY    OF    THE    UMBILICAL   REGION. 


45 


mesenteric  duct  with  its  vessels,  pass 
through  the  umbilical  opening  in 
early  fetal  life.  About  five  or  six 
months  before  birth  all  traces  of 
the  omphalomesenteric  duct  and 
its  vessels  usually  disappear.  The 
right  umbilical  vein  is  gone,  and  the 
urachus  can  generally  be  recognized 
as  a  solid  cord.  Thus  in  the  normal 
umbilicus  at  birth  we  have  to  do 
with  the  remains  of  the  umbilical 
arteries,  the  remnant  of  the  urachus, 
the  occluded  umbilical  vein,  the  peri- 
toneum covering  the  umbilical  re- 
gion, and  lastly  with  the  umbilical 
ring,  and  in  a  certain  number  of 
cases  the  umbilical  fascia. 

In  the  consideration  of  this  sub- 
ject I  shall  dwell  chiefly  upon  the  re- 
sults obtained  by  Gauderon  and  by 
Levadoux,  and  briefly  mention  the 
findings  of  Max  Brodel  during  his 
studies  on  the  embryology  of  the 
umbilical  region. 

In  Figs.  35,  36,  and  37  are  shown 
the  most  common  appearances  of 
the  inner  surface  of  the  anterior  ab- 
dominal wall,  not  only  at  the  um- 
bilicus, but  also  above  and  below 
this  point. 

Gauderon  described  his  findings 
in  10  infants.  He  was  struck  with 
the  variations  in  the  relationship  of 
the  peritoneum  of  the  umbilicus  to 
the  umbilical  cicatrix.  Sometimes 
he  found  the  peritoneum  presenting 


Fig.  37. — The  Umbilical  Regiox  of  ax  Adult, 
Viewed  from  Within-.  (About  half  nat.  size.) 
The  umbilical  ring  is  bridged  over  with  fascial 
bands  running  for  the  greater  part  in  a  transverse 
direction.  There  are  small  globular  masses  of  sub- 
peritoneal fat  distributed  around  the  vessels  and 
the  ring.  Between  these  are  seen  two  small  shal- 
low pits.     The  fibrous  tissue  at  their  bottoms  is 

particularly  strong.  Below  are  seen  the  two  obliterated  hypogastric  (umbilical)  arteries.  Between  them  is  the 
urachus,  passing  from  the  umbilicus  to  the  bladder.  A  portion  of  the  mesentery-like  attachment  to  the  ventral 
body-wall  has  been  removed  so  as  to  show  better  the  size  of  the  structures,  their  relation  to  one  another,  and  to  the 
thin,  band-like  mesenteriolum.  Above,  the  round  ligament  of  the  liver  (obliterated  umbilical  vein)  is  seen  suspended 
from  the  free  border  of  the  triangular  falciform  ligament.  This  ligament  does  not  reach  to  the  umbilicus;  the  round 
ligament  continues  just  under  the  peritoneum,  where  it  may  be  palpated  as  a  broad  band.  From  the  free  border  of 
the  round  ligament  are  seen  hanging  a  few  pedunculated  masses  of  fat.     (Personal  observation.) 


46  THE    UMBILICUS    AND    ITS    DISEASES. 

a  smooth  surface  at  the  umbilicus;  in  other  cases  there  was  a  slight  depression. 
In  a  few  cases — 4  times  out  of  10 — the  peritoneum  was  adherent  to  the  umbilicus; 
in  the  remaining  cases  it  was  free.     Sometimes  it  could  be  easily  separated. 

Before  the  separation  of  the  peritoneum  of  the  umbilicus  it  was  easy  to  deter- 
mine the  existence  or  absence  of  the  umbilical  fascia,  which  forms  the  posterior 
part  of  the,  umbilical  canal  described  by  Richet.  In  some  of  the  cases  the  peri- 
toneum was  not  reinforced  at  the  umbilicus  by  any  trace  of  the  lamellae  composed 
of  fibers  of  the  transversalis  fascia.  Gauderon  says  he  was  able  to  determine  this 
fact  in  an  infant  two  years  of  age.  In  7  of  his  cases  he  encountered  no  other  trace 
of  the  umbilical  fascia  except  portions  of  lamellae  of  the  transversalis,  which  rein- 
force the  peritoneum  for  about  4  or  5  cm.  around  the  umbilicus.  These  lamellae 
are  not  adherent  to  the  posterior  aponeurosis  of  the  rectus  muscle  on  the  right,  and 
as  a  consequence  in  these  cases  one  cannot  say  that  there  exists  a  partial  umbilical 
canal,  as  described  by  Richet.  In  only  2  of  his  10  dissections  did  Gauderon  find  a 
complete  umbilical  canal,  as  described  by  Richet.  One  of  these  subjects  was  a 
child  three  years  old,  the  other,  four  years  old.  In  one  of  these  cases  the  peritoneum 
had  separated  completely  and  one  could  see  clearly  remnants  of  the  umbilical  vein, 
of  the  umbilical  artery,  and  of  the  urachus.  These  were  inserted  to  the  right  of  the 
inferior  half  circumference  of  the  umbilical  ring.  In  consequence,  to  the  left  and 
above  the  ring  was  a  small  depression  in  which  there  was  found  a  small  lump 
of  fat.  According  to  Gauderon,  it  is  in  this  depression  that  the  peritoneum  tends 
to  lie. 

Gauderon  sums  up  his  investigations  as  follows:  In  the  majority  of  infants  the 
umbilical  fascia  shows  defects.  It  was  lacking  8  times  in  10  cases.  When  it  exists, 
it  is  not  so  placed  as  to  reinforce  the  peritoneum  at  the  umbilicus  and  to  protect 
against  distention  or  rupture.  The  umbilicus  is  one  of  the  weakest  parts  of  the 
abdomen. 

The  most  important  article  on  this  subject  is  that  written  by  Levadoux  and  pub- 
lished in  1907.  This  work  was  carried  on  under  the  direction  of  Charpy.  In 
addition  to  comparative  study,  he  examined  50  human  cadavers.  His  investiga- 
tions embrace  the  study  of  the  umbilical  ring  in  mammals,  a  consideration  of  the 
classic  umbilicus,  personal  observations  on  the  varieties  in  the  form  of  the  umbilicus, 
the  form  of  the  outer  umbilicus,  together  with  the  anatomic  formation  of  the  ring, 
and  the  appearance  of  the  inner  surface  of  the  umbilicus. 

I  have  made  a  brief  translation  of  the  salient  features  of  Levadoux's  valuable 
paper,  and  all  the  references  are  exactly  as  the  author  has  given  them. 

From  his  Chapter  II,  I  have  taken  the  following  classic  description  of  the  um- 
bilicus: The  umbilicus  of  the  adult  is  the  orifice  in  the  linea  alba  which  corresponds 
to  the  point  of  attachment  of  the  umbilical  cord  of  the  fetus.  It  is  closed  externally 
by  the  cicatricial  skin,  which  is  adherent  to  its  contour.  Its  inner  surface  is  free, 
and  separated  from  the  abdominal  cavity  by  the  parietal  peritoneum  which  covers 
its  surface.  Sometimes — about  once  in  five  cases — an  umbilical  fascia  of  variable 
thickness  covers  the  ring  and  makes  a  reinforcement  of  the  peritoneum.  This 
opening  with  its  borders  measures  1  cm.  or  more  in  diameter.  It  may  very  well  be 
likened  to  the  mouth  of  a  furnace,  with  its  upper  margin  arched  and  its  lower 
margin  rectangular.  The  central  orifice  is  about  2  to  4  mm.  in  diameter  and  free. 
It  is  closed  solely  by  a  ball  of  fat.  The  margins  of  the  orifice  are  formed  by  the 
oblique  fascia  of  the  aponeurosis  of  the  linea  alba,  to  which  are  added  behind  the 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 


47 


fibers  of  the  arch,  so  that  there  is  formed  a  homogeneous  mass.  The  upper 
border  of  the  ring  is  free;  the  inferior  border  receives  the  insertion  of  the  ura- 
chus,  the  umbilical  arteries,  and  the  umbilical  vein  (Fig.  38)  in  four  separate 
cords. 

The  vein  is  attached  sometimes  to  the  right  or  to  the  center,  and  may  be  divided 
into  filaments.  The  fusion  of  these  various  cords  with  the  base  of  the  ring  results 
in  a  fibrous  nodule  which  is  thick  and  very  adherent  to  the  skin.  The  parietal  peri- 
toneum covers  the  inner  surface  of  the  ring;  it  is  only  lightly  adherent,  and  in  stout 
subjects  is  usually  separated  by  adipose  lobules.  Sometimes  it  passes  directly 
over  the  orifice  and  at  other  times  is  depressed.  At  this  point  only  the  skin  and 
peritoneum  close  the  abdominal  cavity. 

The  umbilical  fascia,  when  it  exists,  extends  upward  for  a  variable  distance. 
It  is  formed  by  the  fibers  of  the  transversalis  fascia  attached  to  the  peritoneum. 
This  may  extend  to  the  margin  of  the  rectus  muscle,  or  join  with  the  posterior  layer 
of  the  aponeurosis.  According  to  Stratz,  a  well-formed  umbilical 
canal  is  situated  high  and  should  be  small.    Hyrtl  compares  the 
umbilical  orifice  in  man  to  that  in  animals. 

In  Chapter  III  Levadoux  takes  up  the  varieties  and  forms 
of  the  umbilicus.     He  considers: 

1.  Varieties  of  the  fibrous  ring. 

2.  Variations  in  the  disposition  of  the  vascular  cords. 

3.  Variations  of  the  umbilical  fascia  and  their  interpreta- 
tion. 

4.  Varieties  of  peritoneum  with  special  reference  to — (a)  the 
formation  of  the  mesoperitoneum;  (b)  fatty  fringes;  (c)  diver- 
ticula;   (d)  atrophy. 

Varieties  of  the  Fibrous  Ring. — This  ring  represents  the 
remains  of  the  passage  of  the  ccelomic  funnel  through  the  linea 
alba.  Its  outer  surface  can  be  studied  after  removal  of  the  skin; 
by  raising  the  peritoneum  one  brings  into  view  the  posterior 
surface.  Viewed  from  its  outer  and  subcutaneous  surface,  this 
ring  is  circular  in  form  and  closely  adherent  to  the  skin  which 
covers  it.  Viewed  from  its  posterior  or  subperitoneal  surface 
also,  it  not  infrequently  appears  circular, — in  22  out  of  50  cases, — but  sometimes  it 
is  elliptic,  the  axis  running  transversely.  One  type  referred  to  by  Blandin  has  the 
form  of  a  semicircle  or  resembles  the  mouth  of  a  furnace  (Fig.  38).  Since  his 
description  appeared,  this  has  been  considered  as  the  normal  type.  Richet,  who 
has  more  recently  considered  this  question,  described  this  orifice  as  quadrilateral, 
with  rounded  angles.  In  the  case  of  individuals  who  have  an  umbilicus  that  is 
nearly  circular,  this  configuration  is  explained  by  the  disposition  and  the  mode  of 
insertion  of  the  umbilical  arteries  and  the  urachus. 

Where  it  has  been  impossible  to  recognize  the  ring,  the  orifice  has  been  found 
completely  closed,  sometimes  by  fusion  of  the  lateral  walls,  sometimes  by  some 
peculiar  arrangement  of  the  vessels.  The  margins  of  this  fibrous  ring  have  a  vari- 
able thickness.  In  a  little  less  than  two-thirds  of  his  cases  Levadoux  could  observe 
no  difference  between  the  thickness  of  the  margins  of  the  ring  and  that  of  the  linea 
alba.     In  several  fat  cadavers  the  fibrous  ring  was  less  thick  than  other  portions  of 


Fig.  38. — Classic  Type 
of       Umbilicus. 
(After  Levadoux.) 
V,  umbilical  vein. 
The    umbilical    arteries 
(Ao,  Ao)  and  the  ura- 
chus   (O)    are   attached 
to  the  lower  margin  of 
the  ring.   Om  represents 
the  ring,  which  is  semi- 
circular.    /  is  the  inter- 
vascular  depression. 


48 


THE    UMBILICUS    AND    ITS    DISEASES. 


the  linea  alba,  and  in  17  of  his  subjects  it  was  manifestly  thicker.  This  reinforce- 
ment was  produced  by  a  fibrous  cushion  on  the  posterior  surface  of  the  ring.  Leva- 
doux  disagreed  with  Richet  that  at  this  point  in  all  cases  superimposed  fibers  were 
present,  but  he  found  that,  when  the  posterior  pad  existed,  he  could  disassociate  a 
certain  number  of  these  fibers  and  determine  that  they  were  not  continuous  with 
the  sheaths  of  the  muscles,  but  terminated  on  a  level  with  the  cushion.  In  all 
probability  Levadoux  had  to  do  here  with  supplementary  fibers.  The  central 
orifice  of  the  ring  measures  from  almost  nothing  to  6  mm.  in  diameter. 

Disposition  of  the  Vessels. — This  is  discussed  at  length  by  Levadoux  (p.  33). 
What  impressed  him  most  in  this  study  was  the  great  diversity  of  types.  The 
majority  of  cases  corresponded  to  the  description  given  by  Robin  (Mem.  de  la  Soc. 
de  Biologie,  1860,  107).     Levadoux  designates  two  main  groups: 

Group    1  .  —  The  inferior  cords  unite  into  one  before  reaching  the  lower 


Fig.  39. — Disposition  of  the  Vasculab  Cords  (Usual 
Type).  (After  Levadoux.) 
Noted  18  times  in  50  cases.  The  peritoneum  has 
been  removed.  The  umbilical  vein  (TO  is  bifurcated 
and  terminates  on  either  side  of  the  ring.  The  urachus 
(0)  and  the  arteries  (Ao,  Ao)  unite  in  C.  F ,  a  depres- 
sion.    B,  a  bridge.      +,  the  umbilical  ring. 


Fig.  40. — Vascular  Cords  op  the  Anastomosing 
Type,  noted  7  Times  in  50  Cases.  (After  Leva- 
doux.) 

The  peritoneum  has  been  removed.  B,  branches 
of  the  umbilical  vein.  M,  an  anastomosis  between  the 
umbilical  vein  and  the  right  umbilical  artery;  C,  a  com- 
mon cord  formed  by  both  umbilical  arteries  and  the 
urachus. 


and  lateral  margins  of  the  fibrous  umbilical  ring.  The  vein  remains  independent 
of  this  cord,  and  is  inserted  as  two  or  three  branches  in  the  superior  or  lateral  walls 
of  the  ring. 

Group  2  .  - — ■  The  inferior  cords  and  the  superior  cord  send  anastomoses* 
reciprocally. 

Levadoux  gives  a  careful  detailed  description  of  the  majority  of  types  encoun- 
tered and  a  classification  according  to  the  frequency  with  which  they  are  found. 

Variety  1  (Fig.  39)  was  noted  18  times  in  50  cases.  The  three  vessels, 
the  urachus  and  the  umbilical  arteries,  unite  at  the  same  point,  4  cm.  below  the 
umbilicus;  the  resulting  cord  is  flattened  in  its  anteroposterior  diameter,  and 
inserted  by  its  upper  extremity  upon  the  inferior  half  of  the  circumference  of  the 
umbilical  ring.     Before  its  termination  the  urachus  is  reduced  to  a  simple  cylindric 

Where  Levadoux  uses  the  term  anastomosis  the  reader  should  consider  it  as  meaning  a  fibrous 
connection  of  the  solid  vessel-walls. 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 


49 


filament,  whereas  the  remnants  of  the  umbilical  arteries  still  retain  a  good  caliber. 
The  vein,  at  a  point  about  6  cm.  above  the  umbilicus,  divides  into  two  cords  of 
equal  size.  These  lie  on  the  lateral  wall  of  the  ring,  and  their  insertions  merge 
with  the  more  lateral  fibers  in  the  inferior  cord.  The  peritoneum  covering  these 
vessels  is  applied  in  such  a  way  that  no  mesentery  for  them  exists. 

Variety  2  (Fig.  40)  was  noted  7  times  in  50  cases.  Here  at  one  point  the 
union  of  the  three  inferior  cords  has  not  taken  place.  The  urachus  has  become 
adherent  to  the  right  umbilical  artery,  about  8  cm.  below  the  umbilicus.  The 
left  artery  joins  the  cord  at  a  point  2  cm.  farther  up.  The  resulting  ligament  is 
inserted  into  the  inferior  and  lateral  borders  of  the  ring.     The  vein  terminates  in 


Fig.  41. — Vascular    Cohd    Type, 
noted   5  Times  in  50  Cases. 
(After  Levadoux.) 
V,  the    umbilical  vein,    which 
passes  downward  and  divides  into 
two  branches,  one  inserted  into  the 
upper  border  of  the  ring,  the  other 
passing  downward  into  the  abdom- 
inal wall.     Ao  and  O  are  the  umbili- 
cal arteries  and  the  urachus  which 
unite  to  form  the  cord  (C)  that  is 
inserted  into  the  left   lateral  wall  of 
the  ring. 


Fig.  42. — Vascular  Cords,  noted 
5   Times  in  50  Cases,   Com- 
pletely Filling  the  Umbili- 
cal Ring.      (After  Levadoux.) 
The     peritoneum      has      been 
raised.     The  umbilical  ring  (+)  is 
closed  by  the   anastomosis  of   the 
cords  on  its  posterior  surface. 


Fig.  43. — Vascular  Cords,  noted 
3  Times  in  50  Cases.  (After 
Levadoux.) 

The  peritoneum  has  been  re- 
moved. The  umbilical  vein  divides 
into  three  branches;  the  umbilical 
arteries  and  the  urachus  are  hyper- 
trophied  and  permeable.  They  ter- 
minate in  delicate  filaments  which 
have  united  to  form  a  common  cord 
(C). 


two  short  branches:  one  is  inserted  into  the  upper  border  of  the  ring,  the  other 
joins  the  right  margin  of  the  ring,  where  it  merges  with  the  fibers  from  the  inferior 
cord.  A  long  branch  from  the  umbilical  vein  passes  downward  and  anastomoses 
with  the  trunk  of  the  right  umbilical  artery.  The  umbilical  vein  then  divides  and 
gives  off  three  branches  which  terminate  in  the  linea  alba  above  the  umbilicus. 

Variety  3  (Fig.  41)  was  noted  5  times  in  50  cases.  The  three  inferior  cords 
unite  as  in  Fig.  40.  The  common  cord  is  short,  and  is  inserted  at  a  point  to  the  left 
of  the  middle  of  the  ring  and  in  its  left  lateral  part.  The  vein  presents  two  long 
branches  of  bifurcation:  one  is  inserted  into  the  superior  border  of  the  ring;  the 
other  passes  to  the  abdominal  wall  and  receives  anastomoses  from  the  left  umbilical 
artery. 
5 


50 


THE    UMBILICUS    AND    ITS    DISEASES. 


Variety  4  (Fig.  42)  was  noted  5  times  in  50  cases.  Here  the  inferior  vessels 
form  a  cord  in  the  same  way.  The  umbilical  orifice  posteriorly  is  completely 
closed.  The  inferior  vessels  and  the  superior  vessels  fuse  together  at  this  point, 
forming  a  continuous  cord  from  the  inferior  surface  of  the  liver  to  the  summit  of  the 
bladder,  and  unite  with  the  lateral  structures  at  the  umbilicus. 

Variety  5  (Fig.  43)  was  noted  3  times  in  50  cases.  The  three  cords  are 
Irypertrophied  and  permeable  up  to  a  certain  point;  they  end  abruptly  as  a  delicate 
cylinder  at  a  point  2  or  3  cm.  below  the  umbilicus,  and  are  inserted  into  the  inferior 
circumference  of  the  ring.     The  vein  divides  into  three  portions,  one  of  which  is 

inserted  into  the  upper  border  of  the  ring,  its  two  lateral 
branches  passing  downward  on  either  side  and  joining  the 
inferior  cord. 

Variety  6  was  noted  3  times  in  50  cases.  The 
urachus  and  the  umbilical  arteries  show  marked  branch- 
ings, and  pass  upward  as  a  network.  The  umbilical  vein 
divides  into  three  branches.  The  middle  one  becomes 
attached  to  the  upper  portion  of  the  umbilical  ring.  The 
lateral  cords  are  continuous  with  the  inferior  filaments. 

Variety  7  was  noted  in  2  out  of  50  cases.  The 
urachus  divides  into  numerous  filaments,  which  disappear 
in  the  linea  alba,  5  cm.  below  the  umbilicus.  The  two 
arteries  form  a  cord  of  small  caliber,  which  terminates  in 
the  linea  alba  at  a  point  5  Cm.  below  the  ring.  The  um- 
bilical vein  bifurcates.  One  of  its  branches  is  inserted  into 
the  right  lateral  margin  of  the  umbilicus;  the  other  anas- 
tomoses with  the  umbilical  arteries. 

Variety  8  (Fig.  44)  was  noted  in  2  out  of  50  cases. 
This  type  is  very  curious,  and  is  found  in  those  subjects  in 
whom  the  cutaneous  cicatrix  does  not  correspond  with  the 
fibrous  ring,  but  is  situated  below  it.     The  two  cords  unite 
before  penetrating  into  the  fibrous  ring.    The  united  trunk 
which  results,  after  passing  through  this  ring,  becomes  sub- 
cutaneous and  is  inserted  all  around  the  cushion  of  the  um- 
bilicus.    The  fibers  forming  the  inferior  cord  describe  a  crook  in  order  to  reach  their 
termination  at  the  umbilicus.     The  vein  has  two  branches  which  terminate  in  the 
skin,  after  having  passed  through  two  orifices  in  the  linea  alba. 


Fig.  44. — Vasculab  Cords, 
noted  in  2  out  of  50 
Cases.  (After  Leva- 
doux.) 

The  umbilical  openings 
do  not  correspond.  The  peri- 
toneum has  been  removed. 
The  inferior  cord  (C)  and  the 
vein  ( V)  pass  through  the  ori- 
fice and  descend  in  front  of 
the  linea  alba  to  become  fixed 
in  the  umbilical  cushion  (B), 
which  is  shown  through  the 
window  cut  out  in  the  ab- 
dominal wall. 


As  a  rule,  the  history  of  the  filaments  resulting  from  obliteration  of  the  umbilical 
vessels  is  as  follows:  The  urachus  and  the  umbilical  arteries  unite  in  a  common  cord 
at  a  variable  distance  from  the  umbilicus.  This  flattened  cord  is  inserted  into  the 
inferior  and  lateral  margins  of  the  ring.  The  umbilical  vein  divides  into  a  variable 
number  of  filaments,  which  are  inserted  most  frequently  into  the  lateral  margins  of 
the  ring — sometimes  into  the  superior  margin.  A  variable  number  of  the  rami- 
fications of  the  vein  and  of  the  inferior  cord  terminate  in  the  abdominal  wall  before 
reaching  the  umbilicus. 

Peri-umbilical  Veins. — On  page  46  Levadoux  discusses  the  peri-umbilical  veins. 
These  have  been  described  by  Sappey,  and  more  recently  by  Jores.  Meriel  has 
also  published  a  note  on  this  subject  (Soc.  anat.  de  Paris,  1902).     This  system 


THE    ANATOMY    OF    THE    UMBILICAL   REGION.  51 

of  veins,  which  results  from  a  union  of  the  vesico-umbilical  veins  and  the  portal 
system,  is  very  interesting.  It  is  formed  by  two  veins,  the  right  and  left  peri- 
umbilical veins,  and  plays  an  important  pathologic  role  in  cases  of  cirrhosis  of  the 
liver.  Jores  considers  the  right  peri-umbilical  vein  as  the  intra-abdominal  portion 
of  the  right  umbilical  vein.  Levadoux  noted  the  presence  of  these  peri-umbilical 
veins,  but  did  not  include  them  in  his  studies. 

Varieties  of  Umbilical  Fascia.- — Levadoux  (p.  46)  describes  the  different  varieties 
of  umbilical  fascia,  and  mentions  the  description  of  it  by  Vidal  de  Cassis  (Des 
hernies  ombilicales  et  epigastriques,  These  de  Paris,  1848).  Later  this  aponeurotic 
sheath  was  described  by  Richet  (Anatomie  med.-chir.  1856-1857),  by  Gauderon 
(These  de  Paris,  1876),  and  Sachs  (Die  Fascia  Umbilicalis.  Arch.  f.  path.  Anat., 
1877).  Richet  called  it  the  "umbilical  fascia."  From  a  study  upon  a  well-formed 
and  well-developed  cadaver  he  found  that  the  peritoneum,  which  envelops  the  um- 
bilical vein,  for  the  last  3  or  4  cm.  above  the  umbilical  ring  is  reinforced  by  a  whitish 
layer  of  fibers  directed  transversely,  and  with  the  edge  at  right  angles  to  the  direc- 
tion of  the  vein.  These  fibers  may  be  continuous  with  the  muscle,  or  they  merge 
below  with  the  posterior  layer  and  the  corresponding  aponeurosis.  Below,  the 
fascia  does  not  pass  to  the  umbilical  cicatrix.  Sometimes,  however,  one  finds  it 
prolonged  and  terminating  imperceptibly  in  the  fibrous  cord  of  the  arteries.  Above, 
it  sometimes  ends  sharply  at  a  point  3  or  4  cm.  from  the  ring.  At  other  times  it  is 
impossible  to  assign  the  precise  limits  of  its  termination.  This  umbilical  fascia, 
though  definite  in  certain  subjects,  is  limited  in  others. 

Richet  considers  the  space  situated  between  the  posterior  surface  of  the  linea 
alba  and  the  umbilical  fascia  as  a  canal,  and  calls  it  the  " umbilical  groove."  This 
canal  contains  in  the  &dult  the  fibro-cellular  cord,  vestiges  of  the  umbilical  vein, 
surrounded  by  a  cellular  tissue,  the  meshes  of  which  in  some  individuals  are  filled 
with  an  abundance  of  yellowish  fat.  Richet  tries  to  establish  a  parallel  between  the 
umbilical  canal  and  the  inguinal  canal.  Gauderon  examined  10  children,  from  two 
to  fifteen  years  of  age,  and  found  the  fascia  well  formed  in  only  two  cases.  In  seven 
cases  it  was  reduced  to  lamellae  which  were  not  adherent  to  the  corresponding  sheath. 

In  speaking  of  variations  in  the  condition  of  the  umbilical  fascia  Sachs  dis- 
tinguished three  groups: 

1 .  The  fascia  does  not  exist  or  ends  far  above  the  upper  border  of  the  ring. 

2.  The  fascia  in  its  inferior  border  is  sharply  defined;  it  covers  the  upper  border 
of  the  ring  or  is  flush  with  it. 

3.  The  fascia  covers  the  entire  ring. 

So  far  as  the  relative  frequency  is  concerned,  Sachs,  from  207  autopsies  made  on 
infants  between  one  and  eleven  months  of  age,  arrived  at  the  following  conclusions : 

Fascia  absent  in 64  cases 

Fascia  present  in 143 

Fascia  covering  the  ring  in 48     " 

Fascia  above  the  ring  or  flush  with  it  in 25 

Levadoux  now  gives  his  own  observations. 

Fascia  absent  in 8  cases 

Fascia  situated  high  and  represented  by  a  bridge  1  cm.  broad  in 9 

Fascia  developed  1  or  more  cm.  in  width,  but  not  reaching  the  su- 
perior border  of  the  ring  in 11 

Fascia  reaching  the  upper  border  of  the  ring  in 7 

Fascia  covering  part  of  the  ring  in 3 

Fascia  covering  all  the  ring  in 5 

Fascia  descending  below  the  ring  in 7 


52 


THE    UMBILICUS    AND    ITS    DISEASES. 


According  to  Levadoux,  the  absence  of  the  fascia  is,  therefore,  much  less  fre- 
quent than  is  indicated  by  Sachs'  figures.  In  the  former's  50  observations  it  was 
lacking  in  only  8  cases  (16  per  cent),  whereas  Sachs  gives  31  per  cent,  a  percentage 
that  is  nearly  double. 

Levadoux  would  explain  this  difference  in  the  findings  by  the  difference  in  the 
ages  of  the  bodies  examined.  Sachs  made  his  observations  on  infants.  Levadoux', 
on  the  contrary,  were  made  upon  adults.  Levadoux  goes  on  to  say  that  in  certain 
cases  the  fascia  may  form  in  the  course  of  the  growth  of  the  individual,  since  we 
know  that  the  fibrous  tissue  does  not  reach  its  full  development  until  after  puberty. 

The  fascia  is  represented  by  a  simple  bridge  which  may  be  easily  overlooked. 
In  such  a  case  it  is  situated  4  or  5  cm.  above  the  umbilicus.  The  fibers  which  form 
it  may  reach  a  breadth  varying  from  several  millimeters  to  one  centimeter,  and  are 


Fig.  45. — Umbilical  Fascia.  Peri- 
toneum in  Place.  (After 
Levadoux.) 

X,  umbilical  ring;  F,  the  um- 
bilical fascia;  R,  the  fringe  of  adi- 
pose tissue;  O,  the  inferior  cord;  V, 
the  umbilical  vein. 


Fig.  46. — Umbilical  Fascia  and 
Umbilical  Mesentery.  (Af- 
ter Levadoux.) 

The  peritoneum  is  in  place.  It 
is  reinforced  by  the  umbilical  fascia 
(F).  V  is  the  umbilical  vein ;  X,  the 
umbilicus.  The  umbilical  arteries 
are  contained  in  a  mesoperitoneum. 


Fig.   47. — Reduplication  of  the 

Linea     Alba.       Peritoneum 

Removed.     (After  Levadoux.) 

The  umbilical  vein  (V)  enters 

by  an  orifice  (T)  into  a  canal  of  the 

linea  alba.     The    posterior  wall   is 

formed  by  the  thickened  fascia  (F) . 

Om,  the  umbilicus;   o,  the  urachus; 

A,  A',  the  arteries. 


always  merged  laterally  with  the  corresponding  sheaths.  They  may  be  disassoci- 
ated or  intimately  blended  together.  In  11  out  of  50  cases  this  umbilical  fascia  was 
formed  of  the  fibers  of  the  transversalis  fascia,  reaching  as  high  as  5  or  6  cm.  Its 
upper  border  was  some  distance  from  the  ring  (Fig.  45).  The  umbilical  vein,  there- 
fore, passes  along  a  canal  formed  by  the  linea  alba  and  this  fibrous  sheath,  which 
varies  in  thickness.  It  is  easy  to  see  that  there  exists  no  groove  at  the  point  of 
entrance  or  disappearance  of  this  ligament.  The  peritoneum  is  intimately  attached 
to  it.  In  7  cases  only  was  fascia  found  reaching  to  the  superior  border  of  the  ring 
(Fig.  46)  and  forming  the  type  of  Richet. 

In  3  cases  the  fascia  descended  a  little  below  the  middle  of  the  ring,  leaving  the 
inferior  part  of  this  orifice  covered  with  peritoneum  only.  Finally,  in  5  cases  the 
fascia  covered  the  ring  completely,  ending  at  its  inferior  border,  and  7  times  it 
descended  3  to  4  cm.  below  its  lower  border. 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 


53 


The  umbilical  fascia  varies,  not  only  as  regards  its  situation  and  extent,  but  also 
in  its  thickness.  In  certain  types  (30  out  of  42)  the  fibers  of  the  transversalis  fas- 
cia, of  which  it  is  constituted,  were  intimately  united;  in  the  other  cases  they  formed 
a  reticulum,  like  a  more  or  less  coarse  meshwork.  In  two  observations  the  fascia 
presented,  toward  the  middle  of  its  extent,  a  rectangular  orifice  3  cm.  long.  Here  a 
zone  of  peritoneal  atrophy  was  noted  (Fig.  48). 

The  relations  of  the  umbilical  vein  to  the  umbilical  fascia  are  nearly  constant. 
The  vein  passes  in  front  of  the  fascia,  which  is  applied  to  the  posterior  surface  of  the 
linea  alba.  Levadoux  says  that  in  its  course  it  is  usually  surrounded  by  adipose 
tissue;  nevertheless,  we  have  one  observation,  communicated  by  Charpy,  which 
does  not  conform  to  this  rule.     In  this  case  the  linea  alba,  10  cm.  above  the  umbili- 


Fig.  48. — Atrophy  of  the  Umbili- 
cal Fascia,  Posterior  View. 
(After  Levadoux.) 
The    peritoneum    is    in    place. 
The  fascia  (F,  F)  presents  two  atro- 
phic    patches,     the    one    lozenge- 
shaped,    the    other  at  the  level   of 
the  umbilicus  (X).      V,  the  umbili- 


Fig.  49. — Formation  of  a  Mesen- 
tery.   Peritoneum  in  Place. 
(After  Levadoux.) 
The  mesentery  (Af)  of  the  um- 
bilical vein  (V)  and  the  mesentery 
of  the   inferior  vascular  cord  (M ') 
form  a  longitudinal   partition.     G, 
fringes  of  adipose   tissue.      X,  the 
umbilicus. 


Fig.  50. — Mesentery  of  the  Ura- 
chus  and  of  the  umbilical 
Arteries.      (After  Levadoux.) 
The  peritoneum  is  in  place.     It 
is  reinforced  by  the  fascia  (F),  be- 
hind which  is  the  vein  (V).     +,  the 
umbilicus.     Below  the  umbilicuses 
the  long  mesentery  (M)  containing 
the  urachus  and  the  umbilical  arter- 


cus,  presented  an  abnormal  thickening  of  3  mm.  (Fig.  47).  The  umbilical  vein  dis- 
appeared into  a  canal  at  a  point  25  mm.  above  the  ring.  The  anterior  part  was 
membranous  and  showed  little  resistance,  whereas  the  posterior  part  was  dense  and 
exceptionally  thick.  This  evidently  represented  not  a  portion  of  the  umbilical  fascia, 
but  a  sort  of  transposition  of  the  linea  alba  behind  the  vein.  When  this  fascia 
exists,  its  superior  and  inferior  margins  are  nearly  always  very  sharp  and  have  an 
arched  arrangement. 

After  having  removed  the  peritoneum,  one  finds  in  a  zone  limited  by  the  crest 
of  the  fascia  a  small  cushion  of  cellular  tissue.  Beneath  the  inferior  margin  of  this 
fascia  this  cushion  is  blended  with  the  transversalis  fascia.  Toward  the  lateral 
borders,  therefore,  says  Richet,  the  transversalis  fibers  merge  with  the  posterior 
portion  of  the  sheath.     Levadoux,  in  dealing  with  pieces  of  fascia  placed  in  formalin 


54 


THE    UMBILICUS    AND    ITS    DISEASES. 


(0.5  per  cent,  for  fifteen  days),  found  it  possible  to  separate  the  umbilical  fascia 
from  its  sheath.  He  says  that  he  carried  out  the  plane  of  cleavage  of  the  aponeurosis 
to  the  transversalis  muscle.  At  its  level  he  could  see  that  the  disassociated  layer 
was  a  continuation  of  the  posterior  sheath  of  the  aponeurosis  developing  from  the 
transversalis  muscle. 

In  36  out  of  50  cases  the  peritoneum  was  applied  intimately  to  the  umbilical 
region,  forming  a  definite  covering.  In  such  cases  the  fibrous  ring  is  not  visible 
from  the  peritoneal  surface.     No  depression  marks  the  umbilical  cicatrix. 

Elevation  of  the  Peritoneum  in  the  Form  of  a  Mesentery. — Normally  the 
umbilical  vein  travels  in  the  free  margin  of  a  mesentery,  a  continuation  of  the  falci- 
form ligament  of  the  liver,  which  is  attached  to  the  anterior  abdominal  wall.  The 
mesentery  is  very  short,  and  terminates  in  the  inferior  part  of  the  liver,  that  is  to 
say,  about  7  or  8  cm.  above  the  umbilicus.     In  3  out  of  50  cases  this  mesentery  ex- 


Fig.  51. — Adipose  Fringes.  From  a  Well-developed 
Young  Woman.  Peritoneum  in  Place.  (After 
Levadoux.) 

The  umbilicus  (A)  is  closed  by  a  pad  of  adipose  tissue. 
V,  the  umbilical  vein;   O,  the  urachus. 


Fig.  52. — Adipose  Fringes  in  a  Stout  Subject.    Peri- 
toneum in  Place.     (After  Levadoux.) 
Om  is  the  umbilicus,  at  the  bottom  of  a  mass  of 
adipose  fringes.      V  is  the  vein.     0  shows  the  inferior 
umbilical  vessels. 


tended  much  farther  down,  reaching  to  within  3  cm.  of  the  superior  margin  of  the 
ring,  while  in  4  other  cases  it  reached  the  upper  border  of  the  ring. 

In  these  4  cases,  besides  the  mesentery  of  the  umbilical  vein,  there  existed  an 
elevation  of  the  peritoneum  over  the  inferior  cords.  These  united  in  a  single  cord 
at  the  summit  of  the  bladder.  They  approached  one  another  at  the  median  line, 
and  raised  the  peritoneum  en  masse  as  far  as  their  insertion  at  the  umbilicus  (Fig. 
49) .  Between  the  umbilical  insertion  of  these  two  mesenteries,  at  the  level  of  the 
posterior  surface  of  the  ring,  there  existed  two  folds  of  peritoneum  containing  fat. 
The  inferior  mesentery  may  also  exist  alone,  as  occurred  in  two  cases  (Fig.  50). 
In  another  case  this  mesentery  was  represented  by  two  peritoneal  elevations  each 
corresponding  to  an  umbilical  artery  (Fig.  46). 

Peritoneal  Fringes  Containing  Fat. — The  peritoneum  may  be  folded,  fringed, 
and  raised  in  folds  to  a'  greater  or  less  degree  by  masses  of  adipose  tissue  which 
infiltrate  the  subserous  tissue.    When  the  fat  attains  a  certain  development,  these 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 


55 


fringes,  as  a  whole,  become  arranged  somewhat  in  the  shape  of  a  collaret  in  which 
the  umbilical  ring  occupies  the  center  (Fig.  51).  Their  existence  is  not  very  rare 
in  the  human  being.  They  are  similar  to  the  epiploic  fringes  of  the  large  intestine,  and 
to  those  of  the  pleura  or  of  the  pericardium,  as  described  by  Cruveilhier  and  more 
recently  by  Poirier.  Occasionally,  the  fatty  umbilical  fringe  presents  an  appear- 
ance similar  to  that  seen  in  Fig.  52.     This  condition  is  also  present  in  the  dog. 

This  disposition  of  the  adipose  tissue  in  the  umbilical  region  is  often  somewhat 
disconcerting  to  the  surgeon,  for  when  working  in  this  area  he  is  at  times  uncertain 
whether  or  not  he  is  really  in  the  peritoneal  cavity.  A  knowledge  of  this  arrange- 
ment of  the  fat  will  prevent  any  confusion  on  his  part. 


DIVERTICULA. 

Levadoux  (p.  61)  takes  up  the  discussion  of  diverticula.  The  peritoneum  pre- 
sented at  the  level  of  the  ring  (14  times  in  50  of  his  cases)  a  more  or  less  pronounced 
diverticular  depression.     In  8  out  of  50  cases  there  were  peri-umbilical  fossettes 


Fig.  53. — Peritoneal  Diverticula.  Peritoneum  in 
Place.  (After  Levadoux.) 
Three  diverticula  (a,  b,  c)  occupied  by  lobules  of 
adipose  tissue,  which  have  been  removed.  X  is  the  um- 
bilicus; V  is  the  umbilical  vein  with  its  three  branches; 
O,  the  urachus. 


Fig.  54. — Peri-umbilical  Fossettes.   Peritoneum  in 
Place.     (After  Levadoux.) 
X  is  the  umbilical  ring,  above  which  are  two  peri- 
toneal fossettes  occupied  by  adipose  tissue,  and  above 
these  again  the  fascia  (F). 


in  the  peritoneum.  The  umbilical  diverticulum  corresponds  to  a  fibrous  ring  more 
or  less  open  behind.  The  peri-umbilical  fossettes  are  found  at  the  breaking  of  the 
linea  alba.  They  are  of  two  kinds,  and  may  exist  together  or  separately  in  the  same 
subject.  The  more  common  form  is  that  resembling  a  crescent.  Sometimes  it 
occupies  the  lateral  portion  of  the  ring,  sometimes  the  inferior  margin;  in  other 
cases  again,  the  other  half  of  the  ring  is  occupied  by  a  mass  of  adipose  tissue.  This 
crescent  may  be  replaced  (6  times  in  14  cases)  by  an  ellipse  which  is  largest  in  its 
transverse  axis,  whereas  in  2  out  of  14  cases  it  was  represented  as  a  round  cupola. 
As  regards  their  relation  to  the  umbilicus,  the  peri-umbilical  fossettes  may 
themselves  be  divided  into  two  groups— the  subumbilical  and  those  situated  above 
the  umbilicus.     The  former  were  noted  by  Levadoux  only  twice  in  50  cases.     Di- 


56  THE    UMBILICUS    AND    ITS    DISEASES. 

verticula  above  the  umbilicus  were  met  with  a  little  more  frequently — 6  times  in 
50  cases.  They  are  usually  multiple,  and  correspond  to  a  defect  in  the  umbilical 
fascia.  Their  arrangement  and  anatomic  constitution  are  characterized  by  the 
presence  of  small  adipose  fringes  which  cover  them  (Figs.  53  and  54).  The  linea 
alba  at  their  level  is  lacking,  and  preperitoneal  lobules  are  found.  In  this  group  of 
peri-umbilical  fossettes  we  have  included  only  those  situated  less  than  3  cm.  from 
the  ring. 


CLINICAL  EXAMPLES  OF  DEFECTS  OF  THE  ABDOMINAL  WALL. 

The  subject  of  defects  in  the  abdominal  wall  presents  many  points  of  interest. 
Two  cases  of  this  character  have  come  under  my  observation. 

In  July,  1910,  I  saw,  in  consultation  with  Dr.  A.  H.  A.  Mayer,  a  boy,  aged  seven- 
teen, who  had  a  small  hernial  protrusion  4  cm.  above  and  to  the  left  of  the  um- 
bilicus. This  hernial  protrusion  projected  1  cm.  through  the  fascia  and  was  lobu- 
lated,  forming  a  mass  3  cm.  in  diameter.  The  patient  was  of  spare  build.  On 
cutting  down  on  the  hernial  sac  I  found  a  small  defect  in  the  abdominal  wall,  through 
which  protruded  a  small  portion  of  the  omentum.  The  omentum  was  readily  re- 
turned, and  the  opening  easily  obliterated  with  a  few  sutures. 

In  the  Journal  of  the  American  Medical  Association  (October  14,  1911,  lvii, 
1251)  I  reported  a  most  unusual  case  of  an  ovarian  tumor  which  had  passed  through 
a  hernial  opening  to  the  outer  side  of  the  right  rectus  and  at  a  point  a  considerable 
distance  from  the  umbilicus.  Although  this  case  is  slightly  foreign  to  diseases  of 
the  umbilical  region,  it  is  of  sufficient  interest  to  warrant  description  here : 

An  Extra-abdominal  Multilocular  Ovarian  Cyst.  — 
On  October  31,  1910,  I  saw,  with  Dr.  Frank  R.  Smith,  a  woman  who  had  a  kidney- 
shaped  tumor  slightly  below  and  to  the  right  of  the  umbilicus.  The  patient  had 
noticed  a  small  lump  in  this  situation  several  years  before,  which,  for  a  long  while, 
had  remained  quiescent,  but  during  the  last  year  had  gradually  increased  in  size. 
At  operation  it  was  found  to  be  a  partly  solid,  partly  cystic  tumor  of  the  ovary, 
lying  external  to  the  abdominal  muscles,  the  tumor  and  its  surrounding  sac  being 
covered  over  with  a  small  amount  of  adipose  tissue  and  the  skin.  The  pedicle  of 
the  tumor  passed  through  a  hernial  ring  to  the  outer  side  of  the  right  rectus  and 
obliquely  across  the  lower  abdominal  cavity  to  what  corresponded  to  the  normal 
insertion  of  the  right  utero-ovarian  ligament. 

I  have  been  unable  to  find  any  reference  to  a  similar  case  in  the  literature. 

History.  —  Mrs.  M.  W.,  aged  fifty-six,  was  a  short,  well-developed  woman, 
and  apart  from  a  tumor  mass  in  the  lower  abdomen  was  in  excellent  health.  She 
had  had  11  children.  Her  periods  had  ceased  at  fifty.  She  had  felt  some  pain  in 
the  right  ovarian  region  for  fifteen  years,  and  for  about  ten  years  she  had  noticed  a 
little  tumor  situated  in  the  right  lateral  abdominal  wall  slightly  above  a  line  drawn 
between  the  umbilicus  and  the  anterior  superior  spine.  This,  from  her  description, 
seemed  to  have  been  about  the  size  of  an  ovary.  During  the  last  ten  months  this 
small  lump  had  increased  in  size  until  it  formed  a  lobulated  mass,  elongate  in  form, 
about  10  by  8  cm.  It  seemed  to  be  but  a  short  distance  beneath  the  skin,  and  could 
be  lifted  up  to  some  extent  in  the  hand,  but  its  absolute  relationship  could  not  be 
determined  on  account  of  the  presence  of  a  considerable  amount  of  adipose  tissue. 

Operation.  —  November  1,  1910.    On  making  a  pelvic  examination  under 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 


57 


anesthesia,  I  found  that  the  uterus  was  normal  and  that  there  was  no  thickening 
laterally.  Not  being  sure  of  the  exact  condition,  I  made  a  median  incision.  The 
uterus  was  normal;  the  left  tube  and  ovary  presented  the  usual  appearance.  The 
right  tube  showed  no  change,  but  the  right  utero-ovarian  ligament  was  markedly 
drawn  out  into  a  band  about  1  cm.  broad.  This  led  to  a  hernial  opening  with 
smooth  margins  in  the  right  lateral  abdominal  wall,  below  and  to  the  right  of  the 


Fig.  55. — Ovarian  Pedicle  Passing  from  Uterus  Out  Through  a  Hernial  Ring  in  the  Abdominal  Wall. 
A  schematic  representation  of  the  pelvic  structures  as  found  at  operation.  The  uterus  and  left  appendages  were 
normal.  The  right  tube  was  unaltered,  but  passing  from  the  uterus,  where  the  right  ovary  should  have  been,  was  a 
band  1  cm.  broad.  This  ran  upward  and  outward  and  passed  out  through  an  abdominal  ring  to  the  outer  side  of  the 
right  rectus.  At  the  ring  a  finger  could  be  passed  completely  around  this  pedicle.  It  was  nowhere  adherent  to  the  ring. 
The  exact  location  of  the  ring  is  well  shown.  On  looking  through  it  a  small  portion  of  the  glistening  tumor  could  be 
readily  seen.     The  dotted  line  indicates  the  relative  size  of  the  tumor. 


umbilicus,  but  at  least  12  cm.  from  the  inguinal  region  (Fig.  55).  After  obtaining 
good  exposure  I  found  that  this  flattened  band  of  the  utero-ovarian  ligament  passed 
directly  into  a  hernial  opening  about  2.5  cm.  in  diameter,  and  into  this  opening  a 
finger  could  readily  be  introduced.  The  intra-abdominal  portion  of  the  pedicle 
was  clamped  off  and  sutured.  An  incision  was  then  made  over  the  prominent  part 
of  the  abdominal  tumor,  which  proved  to  be  extra-abdominal.  The  more  promi- 
nent part  of  this  tumor  lay  directly  beneath  the  skin,  in  the  adipose  tissue,  and  was 


58 


THE    UMBILICUS    AND    ITS    DISEASES. 


very  easily  freed  by  blunt  dissection  to  the  point  where  the  hernial  ring  entered  the 
abdomen.  I  then  cut  the  peritoneum  around  the  hernial  ring  and  delivered  the 
tumor,  with  its  peritoneal  covering  intact.  The  space  occupied  by  the  tumor 
having  been  obliterated,  and  the  inner  incision  having  been  sutured,  the  outer 
wound  was  now  closed.     The  ovarian  tumor  was  multilocular. 

There  had  evidently  been  a  hernial  protrusion  through  the  right  lateral  abdomi- 


Peritoneu 
!     Fascia 


Fig.  56. — Extra-abdominal  Multilocular  Fibrocystoma  of  the  Ovary. 
The  dotted  lines  indicate  the  pelvic  structures  and  the  right  ovarian  pedicle  passing  upward  and  outward  until  it 
emerges  from  the  hernial  ring,  a  short  distance  below  and  to  the  outer  side  of  the  umbilicus.  After  the  abdominal  rela- 
tions had  been  determined,  an  incision  was  made  directly  over  the  tumor,  and  it  and  its  peritoneal  covering  were  re- 
moved intact.  A  thin  layer  of  fascia  and  the  peritoneum  formed  the  sac.  The  tumor  was  roughly  kidney-shaped 
and  lobulated;  it  consisted  partly  of  a  solid  tissue,  partly  of  cysts.  Deep  clefts  subdivided  the  tumor  into  several 
portions.  The  tumor  in  the  main  was  free  from  adhesions,  but  in  a  few  places  there  were  points  of  union  between  it 
and  the  peritoneal  covering.  The  drawing  in  the  right  upper  corner  shows  the  tumor  on  section.  The  fibrous  tissue 
is  abundant,  but  at  this  level  the  cysts  predominate.  The  clefts  are  seen  to  have  extended  through  the  tumor.  It  was 
possible  to  lift  the  various  segments  out  without  disturbing  the  remaining  ones.  Fig.  57  gives  the  real  form  of  the 
tumor  when  liberated  from  pressure. 


nal  wall,  into  which  the  ovary  had  dropped  and  in  which  it  had  remained  for  several 
years.  During  the  last  year  it  had  increased  in  size  and  given  rise  to  a  multilocular 
ovarian  cyst.  Naturally,  with  the  increase  in  size,  the  escape  of  the  ovary  from 
the  sac  had  become  impossible. 

MacroscopicExaminationofHardenedSpecimen  (Path. 
No.  15,723). — The  hernial  opening  was  about  2.5  cm.  in  diameter.     Its  margins 


THE    ANATOMY    OF    THE    UMBILICAL   REGION. 


59 


consisted  of  peritoneum,  outside  of  which  was  a  zone  of  adipose  tissue.  The  tumor 
itself  was  kidnej^-shaped  (Fig.  56),  12  cm.  long,  7  cm.  broad,  and  6  cm.  in  thickness. 
It  was  covered  everywhere  with  peritoneum,  which  could  be  readily  separated  from 
it.  Here  and  there,  attached  to  the  outer  surface  of  the  peritoneum,  were  tags  of 
adipose  tissue.  The  tumor  itself  was  in  large  measure  solid,  resembling  a  fibroma. 
It  presented  a  lobulated  appearance  (Fig.  57).  Here  and  there  between  nodules  it 
showed  cystic  spaces,  oblong,  irregular,  or  round,  varying  from  2  mm.  to  2  cm.  in 
diameter.  The  majority  of  these  were  transparent  and  contained  clear  fluid. 
Some  of  them  were  slightly  blood-tinged.  So  much  could  be  made  out  through  a 
window  which  was  cut  in  the  peritoneum.  On  peeping  in  through  the  hernial  ring 
one  could  see  cysts  varying  from  2.5  cm.  to  3  cm.  in  diameter,  and  apparently 
filled  with  clear  fluid.  After  the  drawing 
had  been  made,  the  tumor  was  cut  in  two. 
The  appearance  on  section  is  well  shown  in 
the  drawing  in  the  right  upper  corner  of 
Fig.  56. 

Histologic  Examination.— 
The  solid  portion  of  the  tumor  consisted  in 
large  part  of  fibrous  tissue  containing  trian- 
gular or  spindle-shaped  nuclei.  In  some 
places  the  nuclei  were  abundant,  in  others 
scanty  in  number.  The  tissue  showed  a 
considerable  degree  of  hyaline  degeneration. 
At  one  or  two  points  characteristic  ovarian 
stroma  was  still  in  evidence.  No  Graafian 
follicles  could  be  found,  but  after  an  exam- 
ination of  numerous  sections  a  typical  corpus 
fibrosum  was  noted.  In  some  sections  a  few 
bundles  of  non-striped  muscle  were  visible. 
The  stroma  had  a  meager  blood-supply,  ex- 
cept in  a  few  areas,  where  there  were  groups 
of  rather  large  veins. 

Scattered  sparingly  through  the  stroma 
were  small  circular  or  irregular  glands,  occur- 
ring singly  or  in  groups  of  two  or  three.  They 
were  found  to  be  fined  with  cylindric  epithe- 
lium, and  were  similar  to  those  so  frequently 

noted  in  the  hilum  of  the  ovary.  Some  of  the  very  small  cystic  spaces,  noted  macro- 
scopically,  were  lined  with  cylindric  ciliated  epithelium  and  had  an  underlying 
stroma  that  stained  rather  deeply  and  that  consisted  of  cells  with  oval  vesicular 
nuclei.  This  stroma  stood  out  in  sharp  contrast  to  the  surrounding  fibrous  tissue. 
Such  cysts  frequently  contained  a  little  fairly  fresh  blood.  They  reminded  one 
very  much  of  the  cystic  spaces  so  frequently  noted  in  an  adenomyoma,  but  I  believe 
that  they  represented  only  the  earlier  stages  of  the  larger  cysts. 

The  large  cysts  were  lined  with  one  layer  of  epithelial  cells,  which  were  cylindric, 
cuboid,  or  almost  flat.  Projecting  into  some  of  the  cysts  were  papillary  folds. 
These  occasionally  occurred  as  delicate,  irregular,  finger-like  projections,  but  in 
the  main  as  blunt,  single,  or  branching  outgrowths.     All  of  them  were  covered  over 


Fig.  57. — An  Extra-abdominal  Multilocttlar 

FlBROCYSTOMA. 

A  schematic  representation  of  the  shape  which 
the  tumor  tended  to  assume,  when  relieved  from  its 
surrounding  pressure.  It  in  reality  consisted  of 
four  lobes  similar  in  character  and  joined  together 
by  broad  or  narrow  pedicles. 


60  THE    UMBILICUS    AND    ITS    DISEASES. 

with  one  layer  of  epithelium.  The  stroma  of  the  papillary  masses  had  in  many 
places  undergone  almost  complete  hyaline  degeneration,  and  in  a  few  liquefaction 
of  this  hyaline  material  had  taken  place.  Even  in  some  of  the  larger  cysts  a  mod- 
erate amount  of  fresh  blood  was  present.  The  stroma  cells  beneath  the  cyst  epi- 
thelium had  in  some  places  become  swollen  and  spheric,  and  were  filled  with  yellow 
or  brown  pigment,  indicating  the  absorption  of  blood  at  some  previous  time. 

On  the  surface  of  the  tumor  were  a  moderate  number  of  vascular  adhesions,  and 
on  the  under  and  protected  side  of  these  the  peritoneal  cells  had  become  cuboid, 
as  is  common  on  the  under  side  of  tubal  or  ovarian  adhesions. 

From  the  above  description  it  will  be  seen  that  the  dense  matrix  of  the  tumor 
consisted  essentially  of  fibrous  tissue,  and  that  scattered  throughout  this  were 
multiple  cysts,  in  large  measure  similar  in  character,  some  of  which  had  small  papil- 
lary masses  projecting  into  them.  Had  the  tumor  developed  in  the  abdominal 
cavity,  I  believe  that  in  all  probability  it  would  have  been  a  multilocular  cystoma, 
but  as  it  lay  between  the  abdominal  muscles  and  skin,  a  rapid  cystic  growth  was 
much  more  difficult,  and  the  fibrous  tissue  was  thus  allowed  to  keep  pace  with  the 
cystic  formation. 

There  was  no  sign  of  malignancy. 

Dr.  Bloodgood  tells  me  that  he  observed  a  case  of  hernia  of  the  abdominal  wall 
at  the  semilunar  line,  that  was  between  the  rectus  muscle  and  those  forming  the 
lateral  abdominal  wall.  The  sac  contained  non-adherent  loops  of  small  bowel. 
The  condition  was  readily  cured.  In  our  case  the  opening  was  also  at,  or  near,  the 
semilunar  line,  but  instead  of  small  bowel,  the  ovary  had  for  some  reason  occupied 
the  space  and  later  had  gone  on  to  tumor  development.  It  is  just  possible  that  this 
weakness  in  the  wall  had  become  particularly  accentuated  during  a  pregnancy,  and 
that  the  ovary,  during  its  ascent  with  the  pregnant  uterus,  had  dropped  into  the 
cavity.  The  possibility  of  an  embryonic  displacement  of  the  ovary  cannot,  of 
course,  be  excluded. 


THE  RELATION  OF  THE  OUTSIDE  OF  THE  UMBILICUS  TO  THE  PERITONEAL  SIDE. 

Out  of  13  complete  umbilici,  in  8  Levadoux  noted  a  posterior  umbilical  fossette; 
in  the  other  5  cases  the  orifice  was  well  closed  by  the  umbilical  fascia,  which  de- 
scended to  its  inferior  border.  When  the  fascia  was  raised,  the  fibrous  ring  was 
readily  seen  to  be  more  or  less  open  behind.  In  the  9  umbilici  showing  the  teat- 
like elevation,  without  cushion,  in  3  there  was  a  corresponding  peritoneal  fossette; 
four  others  had  only  fascia  covering  the  posterior  opening  of  the  fibrous  ring;  in  the 
2  others  the  fascia  and  fossette  were  absent.  The  opening  was  well  closed  by  cord- 
like branches  of  the  vessels.  The  type  of  the  incomplete  umbilicus,  with  cushion 
and  without  teat-like  elevation,  is  much  more  common  (in  23  out  of  50  cases) . 
Frequently  it  shows  a  well-closed  fibrous  orifice.  In  3  cases  only  did  Levadoux 
note  the  peritoneal  fossette;  in  4  cases  the  umbilical  fascia  descended  behind  the 
ring.  Out  of  15  cases,  in  9  the  orifice  was  closed  by  a  simple  reapproachment  of 
the  margins,  in  6  by  a  soldering  of  the  margins  and  anastomosis  of  the  fibrous  cord 
of  the  inferior  umbilical  with  the  superior  umbilical  vessels.  As  a  result  of  these 
studies  Levadoux  draws  the  following  conclusions: 

(1)  The  teat-like  elevation  of  the  umbilicus  corresponds  nearly  always  with  the 
fibrous  ring,  which  is  open. 


THE    ANATOMY    OF    THE    UMBILICAL   REGION.  61 

(2)  When  the  cutaneous  umbilicus  is  complete,  in  the  majority  of  cases  (8  out 
of  13)  an  umbilical  peritoneal  fossette  is  present. 

(3)  The  umbilicus  without  the  teat-like  elevation  usually  corresponds  to  a  fibrous 
ring  that  is  closed  (24  out  of  27  times).     The  same  holds  good  in  obese  subjects. 

(4)  The  existence  or  the  non-existence  of  the  umbilical  fascia  at  the  level  of  the 
fibrous  ring  bears  no  relation  to  the  cutaneous  form  of  the  umbilicus. 

Having  gone  fully  into  the  findings  of  Levadoux,  I  shall  merely  mention  the 
results  obtained  by  Brodcl  in  his  studies  of  the  embryology  of  the  umbilical  region. 

Fig.  16  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
6.5  cm.  long. 

Fig.  17  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
7.5  cm.  long. 

Fig.  18  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 

9  cm.  long. 

Fig.  19  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 

10  cm.  long. 

Fig.  20  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
12  cm.  long. 

Fig.  21  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
12  cm.  long. 

Fig.  22  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
12  cm.  long. 

Fig.  24  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
15  cm.  long. 

Fig.  28  gives  th£  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
about  five  months  old. 

Fig.  29  gives  the  intraperitoneal  view  of  the  umbilicus  in  a  human  embryo 
six  to  seven  months  old. 

These  pictures  show  the  relations  of  the  umbilical  arteries  to  the  urachus,  and 
their  mode  of  termination  at  or  near  the  umbilical  ring.  They  also  give  the  rela- 
tions of  the  umbilical  vein.  They  show  the  appearance  of  the  umbilical  ring  as 
viewed  from  the  abdomen,  and  depict  the  mesenteries  frequently  found  supporting 
the  umbilical  vessels  and  the  urachus. 

Figs.  35,  36,  and  37  give  accurate  types  of  the  adult  umbilicus  as  seen  at 
operation  or  at  autopsy. 

THE  UMBILICUS  IN  ANIMALS. 

In  a  comparative  study  of  the  umbilicus  Levadoux  examined  two  species  of 
hoofed  animals,  the  horse  and  the  donkey.  He  examined  ten  horses  and  two 
donkeys.  In  these  animals  the  umbilicus  is  represented  by  an  ellipsoid  depres- 
sion, arranged  in  a  cranio-caudal  direction.  Posteriorly  it  is  bounded  by  a  smooth 
surface  and  a  rudimentary  vestige  of  a  cutaneous  cicatrix.  In  front  of  this  the 
hairs  have  a  disposition  to  diverge,  on  account  of  a  sagittal  line  which  forms  a 
grand  axis  of  the  depression  and  produces  what  may  be  termed  a  "tuft."  This 
disposition  of  the  hair  is  entirely  contrary  to  that  observed  in  man,  where  the 
hairs  of  the  umbilical  region  converge  toward  the  umbilicus. 

Levadoux  (p.  18)  says  that  in  mammals  there  exists  a  cutaneous  depression, 
circular  in  form,  and  completely  covered  with  hair,  located  in  the  median  abdominal 
line  at  the  same  height  as  in  the  solipeds. 


62  THE    UMBILICUS    AND    ITS   DISEASES. 

For  rodents  Levadoux  confined  his  observations  to  the  mouse,  water-rat, 
guinea-pig,  and  rabbit.  In  the  mouse  and  in  the  rat  nothing  can  be  seen  from  the 
outer  surface  to  indicate  the  point  of  implantation  of  the  umbilical  cord.  In  the 
guinea-pig,  on  the  other  hand,  toward  the  middle  of  the  median  abdominal  line,  is 
seen  a  circular  surface  divested  of  hair,  somewhat  prominent,  and  about  3  mm.  in 
diameter.  It  is  surrounded  by  a  circular  furrow,  and  suggests  the  elevation  in  the 
human  umbilicus.  Thus,  the  cutaneous  abdominal  cicatrix  is  absent  in  the  mouse 
and  rat.  The  hairs  have  no  special  disposition.  The  rabbit  does  not  present  the 
cutaneous  umbilical  cicatrix,  but  the  linea  alba  is  clearly  visible  throughout  the 
entire  length  of  the  recti  muscles. 

The  carnivora  are  then  dealt  with  (p.  23).  The  cat  and  the  dog  were  studied. 
So  far  as  regards  the  umbilical  region,  the  cat  has  nothing  to  distinguish  it  from  the 
rabbit.  The  anatomy  of  the  umbilical  region  of  the  dog  is  more  interesting,  be- 
cause it  resembles  more  closely  that  found  in  the  human  being.  The  cutaneous 
surface  of  the  umbilicus  presents  teat-like  projections,  smooth  or  covered  with  silky 
hair-follicles  which  project  to  a  greater  or  less  extent.  Surrounding  this  teat-like 
projection  is  a  furrow,  and  sometimes  around  the  furrow  is  a  remnant  of  a  cushion. 
This  arrangement  was  noted  in  7  out  of  10  cases.  In  the  other  cases  the  teat-like 
projections  were  lacking,  and  Levadoux  found  nothing  more  than  a  depression.  All 
the  abdominal  hair  converged  toward  the  umbilicus. 

The  inner  surface  of  the  umbilicus  of  the  horse  and  donkey  shows 
a  lozenge-shaped  hollow  which  corresponds  to  the  cutaneous  depression.  This  is 
surrounded  in  all  directions  by  a  fibrous  cord  which  is  half  cylindric  and  firmly 
attached.  The  two  cords  which  are  formed  of  longitudinal  fibers  unite  at  the  two 
extremities  of  the  lozenge  and  terminate  in  the  linea  alba,  4  or  5  cm.  from  their 
point  of  union.  On  transverse  section  at  the  site  of  this  depression  the  fibrous 
thickenings  are  seen  to  be  formed  from  the  subjacent  fibers,  which  become  merged 
with  those  of  the  linea  alba.  The  fibers  in  the  linea  alba  have  a  radiating  direction 
as  regards  this  lozenge,  and  the  deeper  ones  are  inserted  in  its  margins.  At  its 
anterior  extremity,  at  the  point  of  reunion  of  the  two  pillars,  it  is  represented  by  a 
cylindric  cord  which  is  the  remains  of  the  umbilical  vein.  This  cord,  which  is  in- 
timately connected  with  the  abdominal  wall  by  the  peritoneum,  terminates  in  the 
inferior  surface  of  the  fiver.  In  the  solipeds  there  does  not  exist  a  vestige  of  the 
urachus  or  of  the  umbilical  arteries.  The  peritoneum  which  covers  the  bottom  of 
this  depression  is  separated  by  the  transversalis  fascia. 

On  page  18  he  briefly  describes  the  inner  appearance  of  the  umbilicus  in  rumi- 
nants— the  cow  and  the  sheep.  On  page  20  he  takes  up  the  consideration  of  the 
rodents  and  describes  the  inner  appearance  of  the  umbilicus  in  the  mouse,  water- 
rat,  guinea-pig,  and  rabbit. 


THE  LYMPHATICS  OF  THE  UMBILICAL  REGION. 
Relatively  little  has  been  written  on  the  lymphatics  of  this  region,  either  by  the 
clinician  or  the  anatomist.  The  former  studied  the  manner  in  which  abdominal 
carcinomata  reach  the  umbilicus,  and  the  mode  of  dissemination  of  primary  um- 
bilical growths,  whereas  the  anatomist  has  reached  his  conclusions  by  injecting 
the  lymphatics  of  the  umbilical  region.  Although  our  knowledge  of  the  subject 
is  as  yet  by  no  means  complete,  the  findings  are  of  much  interest. 


THE    ANATOMY    OF    THE    UMBILICAL   REGION.  63 

In  Figs.  58  and  59  Max  Brodel  has  given  us  composite  pictures  of  what  is  known 
of  the  umbilical  lymphatics. 

Neveu,  in  1890,  speaking  of  secondary  malignant  tumors  of  the  umbilicus,  says 
that  the  superficial  lymphatics  below  the  umbilicus  pass  to  the  inguinal  glands, 
while  the  superficial  lymphatics  above  the  umbilicus  pass  to  the  axillary  glands. 
The  deeper  umbilical  lymphatics  situated  just  external  to  the  peritoneum  are  very 
abundant,  especially  in  the  median  line.  The  deep  lymphatics  below  the  umbilical 
region  pass  to  the  iliac  glands;  those  above  the  umbilicus  go  to  the  retrosternal 
glands.     Neveu  then  briefly  quotes  Sappey's  findings. 

Quenu  and  Longuet,  in  their  exhaustive  monograph  on  secondary  cancer  of  the 
umbilicus  (1896),  say  that  the  lymphatics  constitute  an  excellent  avenue  along 
which  abdominal  carcinomata  may  reach  the  umbilicus.  They  describe  the  manner 
in  which  the  lymphatics  of  the  pyloric  end  of  the  stomach  and  those  of  the  duodenum 
communicate  with  those  of  the  under  surface  of  the  liver.  From  this  point  there  is 
a  free  lymphatic  communication  with  the  umbilicus  along  the  suspensory  ligament. 

Speaking  of  the  mode  of  extension  of  pelvic  carcinomata  to  the  umbilicus,  these 
authors  say  that  certain  lymphatics  of  the  uterus  pass  along  the  round  ligament 
to  the  inguinal  glands,  and  at  times  to  the  iliac  glands;  that  there  is  a  free  lymphatic 
communication  between  the  umbilicus  and  the  inguinal  and  iliac  glands,  and  con- 
sequently there  is  a  direct  connection  between  the  pelvic  lymphatics  and  the  um- 
bilicus. 

Le  Coniac,  in  1898,  when  considering  carcinoma  of  the  umbilicus,  secondary  to 
carcinoma  of  the  uterus  or  ovaries,  says  that  a  direct  lymphatic  path  can  be  traced 
from  the  pelvis  to  the  umbilicus.  He  quotes  the  studies  of  Poirier,  who  also  found 
that  some  of  the  uterine  lymphatics  pass  to  the  inguinal  region,  while  others  enter 
the  iliac  glands.  From  either  the  inguinal  or  iliac  glands  the  cancer  may  extend 
to  the  umbilicus,  in  the  later  part  of  the  journey  probably  passing  against  the 
lymph  current.  In  the  chapter  on  Cancer  of  the  Umbilicus  the  following  occurs : 
"The  careful  study  of  many  umbilical  lesions  in  the  past  has  demonstrated  that 
when  the  liver  is  involved  in  a  malignant  growth,  which  has  extended  to  or  en- 
croached upon  the  suspensory  ligament,  the  growth  tends  to  pass  by  way  of  the 
lymphatics  out  along  the  suspensory  ligament  to  the  umbilicus.  When  a  malig- 
nant pelvic  growth  extends  to  the  umbilicus,  it  usually  follows  the  lymphatics  found 
in  the  course  of  the  remnants  of  the  obliterated  umbilical  arteries  and  urachus  up- 
ward to  the  umbilical  depression.  If  the  umbilicus  is  the  seat  of  a  malignant  growth, 
the  inguinal  or  axillary  glands  may  be  secondarily  involved  according  as  the  growth 
occupies  the  upper  or  lower  part  of  the  umbilicus." 

Of  special  interest  are  the  reports  of  primary  and  secondary  carcinomata 
(pp.402,  412),  in  which  is  given  a  clear  description  of  the  various  avenues  along 
which  the  carcinoma  may  extend. 

An  Anatomic  Study  of  the  Umbilical  Lymphatics. 
Cuneo  and  Marcille,  in  1901,  injected  the  umbilical  lymphatics  in  10  new-born 
children,  and  divided  them  into  three  groups,  of  which  they  gave  the  following- 
description  : 

1.  Cutaneous  lymphatics. 

2.  Lymphatics  of  the  fibrous  umbilical  thickening. 

3.  Lymphatics  of  the  aponeurosis  surrounding  the  umbilical  ring. 


64 


THE    UMBILICUS    AND    ITS    DISEASES. 


,  .-..-.in  eJi 


Fig.  .58. — Superficial  Lymphatics  of  the  Umbilical  Region-. 
This  is  a  composite  drawing  based  on  the  studies  of  Cuneo  and  Marcille.     The  bulk  of  the  lymph-channels  pass 
in  the  subcutaneous  fat  and  are  seen  to  drain  in  four  directions,  the  upper  set  passing  to  the  axillary  lymph-glands, 
while  the  lower  empty  into  the  external  inguinal  group.     On  the  left  side  of  the  picture  a  small  portion  of  the  sub- 
cutaneous fat  has  been  removed,  showing  branches  of  the  deeper  lymphatics  resting  on  the  muscular  aponeurosis. 


THE    ANATOMY    OF    THE    UMBILICAL    REGION. 


65 


Fig.  59. — The  Deep  Umbilical  Lymphatics  as  seen  from  the  Peritoneal  Side. 
This  is  a  composite  drawing,  based  on  the  studies  of  Cuneo  and  Marcille  and  Poirier.  Like  the  superficial  lymph- 
atics, the  deep  likewise  drain  chiefly  upward  and  downward.  Those  from  the  upper  umbilical  region  pass  on  either  side 
of  the  falciform  ligament  of  the  liver,  pierce  the  diaphragm,  and  enter  the  anterior  mediastinal  glands.  In  their  course 
small  intercalated  lymph-glands  are  occasionally  found.  An  additional  small  lymph-channel  is  found  along  the  course 
of  the  round  ligament  of  the  liver.  It  is  along  this  channel  that  cancers  of  the  stomach  and  gall-bladder  find  their  way 
to  the  umbilicus.  The  lymphatics  from  the  lateral  portions  of  the  umbilicus  first  pass  outward  and  then,  curving  down- 
ward, reach  the  inguinal  glands.  The  lymphatics  from  the  lower  portion  of  the  umbilicus  pass  directly  downward  to 
the  internal  inguinal  glands. 

6 


66  THE    UMBILICUS    AND    ITS    DISEASES. 

Iii  the  new-born  the  cutaneous  lymphatics  originate  from  the 
''umbilical  scrotum."  They  form  a  thin  network  which  is  difficult  to  inject.  This 
network  is  continuous  with  that  of  the  surrounding  skin.  From  the  umbilicus, 
four  or  five  trunks  pass  in  each  direction  immediately  beneath  the  skin.  They  go 
downward  and  outward  toward  the  fold  in  the  groin,  and  terminate  in  two  groups 
of  glands — the  superficial  external  and  the  superficial  internal  inguinal  glands.  It 
is  unusual  to  see  these  lymph-trunks  descending  and  passing  over  to  the  median 
line. 

At  the  level  of  the  umbilicus  these  authors  were  never  able  to  inject  a  lymph- 
trunk  that  passed  to  the  axillary  glands. 

The  lymphatics  of  the  fibrous  cord  were  still  more  difficult 
to  inject.  From  the  fibrous  cicatrix  two  or  three  lymph-trunks  pass  in  each  di- 
rection and  disappear  immediately  in  the  sheath  of  the  corresponding  muscle. 

The  lymphatics  of  the  aponeurosis  of  the  umbilical 
ring  are  divided  into  two  groups — the  anterior  and  the  posterior.  The  an- 
terior lymphatics  originate  in  the  anterior  or  cutaneous  surface  of  the 
corresponding  sheath  as  a  delicate  network  which  encircles  the  umbilical  ring. 
The  resultant  lymph-trunks  are  divisible  into  two  groups.  In  the  first  and  more 
important  they  run  parallel  to  the  sheath  of  the  aponeurosis,  disappear  in  it,  and 
unite  with  those  arising  from  the  fibrous  nodule.  In  the  other  the  lymph-trunks 
pass  outward  parallel  to  the  two  obliques,  and  may  be  confused  with  those  from 
the  posterior  aponeurosis. 

The  posterior  lymphatics  originate  from  a  network  attached  to 
the  posterior  or  peritoneal  surface  of  the  sheath.  The  collectors  of  this  network 
may  be  divided  into  two  groups.  In  the  first  the  lymphatics  pass  upward  and  unite 
with  the  corresponding  lymphatics,  which,  as  we  have  seen,  originate  from  the  an- 
terior part  of  the  sheath  of  the  muscle.  These  trunks  follow  their  course  in  the 
sheath  and  terminate  in  the  external  iliac  gland,  resting  on  the  anterior  part  of  the 
iliac  artery.  The  other  trunks  emanating  from  the  posterior  aponeurotic  network 
pass  downward  in  company  with  the  vessels  from  the  fibrous  thickening,  and  usually 
accompany  the  epigastric  artery,  descending  and  terminating  in  the  two  external 
iliac  glands  immediately  behind  the  crural  arch.  In  the  course  of  these  lymph- 
trunks  one  may  encounter  from  two  to  four  glands,  sometimes  of  small  volume, 
which  invariably  accompany  the  epigastric  artery.  These  are  the  epigastric  glands 
of  Gerota. 

Cuneo  and  Marcille,  in  three  out  of  ten  cases,  observed  a  small  gland  situated 
in  the  subperitoneal  cellular  tissue,  2  to  4  cm.  below  the  umbilicus.  This  gland  is 
always  a  little  to  one  side  of  the  median  line.  It  was  mentioned  by  Gerota  in  his 
work. 

In  one  case  they  found  two  subperitoneal  glands  close  to  the  umbilicus.  They 
found  that  the  lymphatics  of  the  umbilicus  anastomose  with  those  of  the  liver  and 
of  the  bladder  by  means  of  the  lymphatic  network  which  surrounds  the  umbilical 
vein  and  the  network  following  the  umbilical  arteries  and  the  urachus. 


THE  SENSORY  NERVE-SUPPLY  OF  THE  UMBILICUS. 
Spiller  reviewed  the  literature  on  this  subject  in  the  Philadelphia  Medical  Jour- 
nal, February  8,  1902,  and  reported  a  case  that  he  had  had  under  observation. 


THE    ANATOMY    OF    THE    UMBILICAL    REGION.  »;- 

Spiller  and  Weisenburg  (1904)  discussed  the  subject  still  further.  Boettiger 
had  been  uncertain  whether  the  umbilicus  lies  in  the  distribution  of  the  ninth  or  of 
the  tenth  thoracic  segment.  Walton  had  put  it  in  the  distribution  of  the  eleventh 
thoracic  segment;  Dejerine  in  the  distribution  of  the  tenth  thoracic  segment. 
Head  had  attributed  to  the  tenth  thoracic  sensory  segment  the  supply  of  the  sub- 
umbilical  region,  and  had  described  the  upper  border  of  the  segment  as  passing 
directly  through  the  umbilicus.  Spiller  and  Weisenburg  say:  "From  this  review 
it  will  be  seen  that  there  is  much  to  be  said  in  favor  of  the  situation  of  the  umbilicus 
within  the  tenth  thoracic  sensory  segment,  but  this  is  an  opinion  we  are  unable  to 
accept."  In  a  preceding  paper  Spiller  had  reported  a  ease  indicating  that  the  um- 
bilicus lies  between  the  ninth  and  tenth  thoracic  sensory  segments,  and  in  a  later 
paper  a  second  case  that  was  observed  until  death.  From  the  data  thus  obtained 
Spiller  and  Weisenburg  think  that  the  umbilicus  probably  lies  within  the  zone  of  the 
ninth  thoracic  segment.  They  say  that  the  importance  of  this  determination  must 
be  apparent  on  account  of  the  prominence  of  the  umbilicus  as  a  surgical  landmark. 


THE  SKIN  UMBILICUS. 
Runge,  in  his  chapter  on  '"Wound  Infections  of  the  New-Born"  (p.  61..  says 
that  at  the  fetal  end  of  the  cord  the  amnion  passes  directly  to  the  skin  of  the 
child.  This  point  of  transition  occurs,  as  a  rule,  from  0.5  to  1  cm.  out  on  the  cord, 
and  ends  in  a  ring-shaped  swelling.  If  the  skin  passes  farther  out  on  the  cord,  it  is 
spoken  of  as  a  skin  or  flesh  umbilicus.  It  is  the  antithesis  of  an 
amniotic     umbilicus. 


THE  AMNIOTIC  UMBILICUS. 

Nicaise,  in  1881,  referred  to  this  very  rare  condition.  He  said  that,  according 
to  Widerhofer,  it  is  characterized  by  an  absence  of  skin  around  the  umbilicus,  the 
defect  being  replaced  by  amnion  which  is  reflected  upon  the  abdomen  from  the  cord. 
In  such  cases  the  surrounding  abdominal  wall  is  usually  intact.  The  amniotic 
umbilicus  is  small,  and  does  not  interfere  with  the  health  of  the  child.  In  the  ease 
mentioned  by  Nicaise  the  amniotic  disc  was  gradually  replaced  by  scar  tissue  and 
the  umbilicus  completely  closed. 

Runge,  in  1893,  when  discussing  this  subject,  said  that  in  rare  cases  there  is  a 
preponderance  of  amnion  and  a  lack  of  skin  at  the  umbilicus.  The  amnion  spreads 
out  as  a  flat  funnel  around  the  umbilicus,  and  the  condition  is  spoken  of  as  an 
amnion    umbilicus. 

A  careful  study  of  Fig.  2,  p.  2,  Fig.  3.  p.  3,  Fig.  197,  p.  462,  will  render  clear 
the  mode  of  development  of  the  amnion. 


ABSENCE  OF  THE  UMBILICUS. 
As  pointed  out  by  Xicaise,  the  umbilicus  may  be  confounded  with  the  upper 
portion  of  an  exstrophy.  In  such  a  case  it  is  more  distinct  behind  than  in  front  of 
the  abdominal  wall.  Sometimes  it  is  situated  immediately  above  the  exstrophy; 
more  rarely  it  is  3  or  4  cm.  distant  from  it.  The  umbilical  vein  may  be  longer  than 
normal.     The  umbilical  arteries  are  slender  and  shorter.     The  urachus  is  wanting 


68  THE    UMBILICUS    AXD    ITS    DISEASES. 

when  the  umbilicus  corresponds  to  the  upper  portion  of  the  exstrophy.  In  such 
cases  there  is  no  real  absence  of  the  umbilicus,  but  an  unusual  disposition  of  it,  due 
to  the  exstrophy,  which  in  turn  is  caused  by  the  failure  of  the  allantois  and  of  the 
abdominal  walls  to  close. 

Evans,  in  1895,  referred  to  a  young  white  man  who  virtually  had  no  umbilicus — 
there  was  scarcely  any  depression,  the  parts  being  quite  flush  with  the  abdominal 
wall.  As  noted  on  page  62,  there  is  no  trace  of  the  umbilicus  in  certain  animals, 
and  if  the  surgical  treatment  of  the  cord,  as  carried  out  by  Dickinson,  Flagg,  and 
Buckmaster,  were  generally  adopted,  it  would  not  be  long  before  many  adults  would 
have  but  the  faintest  suggestion  of  an  umbilicus. 


THE  UMBILICUS  DURING  PREGNANCY. 

According  to  Xicaise,  modifications  of  the  umbilicus  during  pregnancy  have 
been  studied  chiefly  by  Dubois,  Cazeaux,  and  Stoltz.  Catteau  has  also  described 
them.  Xicaise  says  that  alterations  in  the  umbilicus  differ  in  the  primipara  and  in 
the  multipara.  After  the  first  and  second  months  of  the  first  pregnancy  the  um- 
bilicus is  drawn  in  a  little;  the  patient  has  a  sensation  of  a  painful  pulling  at  this 
point,  and  the  umbilical  region  has  an  increased  sensibility.  At  the  third  or  fourth 
month  the  umbilicus  is  normal,  but  the  umbilical  area  is  slightly  raised.  In  small 
patients  the  changes  are  more  rapid  and  more  marked.  At  term  the  umbilicus 
itself  is  generally  raised  a  little  above  the  surrounding  parts,  and  its  dimensions  are 
increased.  (Plate  IV,  60,  and  Plate  VI,  4.)  Sometimes  the  umbilical  ring  is  dilated 
and  permits  the  introduction  of  the  tip  of  the  ringer.  The  umbilical  cicatrix  is 
more  easily  depressed,  and  the  umbilical  furrow  is  less  marked.  Hernia  of  the 
intestine  or  of  the  omentum  rarely  follows  a  first  pregnancy. 

During  the  following  pregnancies  the  modification  of  the  umbilicus  is  more 
marked  and  more  rapid,  and  the  umbilicus  is  readily  distended.  At  the  ninth 
month  the  umbilicus  itself  has  unfolded,  and  is  even  with  the  abdominal  wall. 
Xicaise  says  that  the  umbilicus  at  this  time  is  distinguished  only  by  the  white  col- 
oration above  and  by  the  fine  character  of  the  skin  of  the  scar. 

The  umbilical  areola,  according  to  Xicaise,  is  rare.  He  quotes 
Montgomery,  who  says  that  a  brownish  zone  at  times  completely  surrounds  the 
umbilicus,  and  forms  an  areola  analogous  to  that  of  the  breasts. 

Evans,  when  discussing  the  subject  in  1895,  said  that  an  umbilical  areola  is  an 
unimportant  secondary  sign  of  pregnancy,  for  by  the  time  that  the  condition  has 
advanced  sufficiently  to  cause  bulging  at  the  umbilicus,  the  diagnosis  is  usually 
clear. 


LITERATURE    CONSULTED    ON    ANATOMY    OF    THE    UMBILICAL    REGION. 

Bert,  A.,  et  Yiannay,  Charles:  Etude  sur  la  morphologic  de  l'ombilic.     Compt.  rend,  de  l'assoc. 

des  anatomistes,  104,  vi,  116. 
Catteau,  J.  F.:  De  l'ombilic  et  de  ses  modifications  dans  les  cas  de  distension  de  l'abdomen. 

These  de  Paris,  1876,  No.  210. 
Cullen,  Thomas  S. :    An  Extra-abdominal  Multilocular  Ovarian  Cyst.  Jour.  Amer.  Med.  Assoc, 

October  14,  1911,  lvii,  1251. 
Cuneo  et  Marcille:    Lymphatiques  de  l'ombilic.    Bull,  de  la  Soc.  anat.  de  Paris,  1901,  annee  76, 

580. 


THE    ANATOMY    OF    THE    UMBILICAL   REGION.  69 

Evans,  T.  R.:  Umbilical  Freaks;  Rationale  of  Umbilical  Depression  in  Early  Pregnancy.  Gail- 
lard's  Med.  Jour.,  1S95,  lxi,  28. 

Gauderon,  A.  E.:  De  la  peritonite  idiopathique  aiguedes  enfants;  de  sa  terminaison  par  suppura- 
tion et  par  evacuation  du  pus  a  travers  l'ombilic.     These  de  Paris,  1876,  No.  148. 

Hertz,  W.  H.:  Ueber  einen  Fall  von  Adenocarcinom  des  Nabels  bei  einer  58-jahr.  Frau.  Inaug. 
Diss.,  "Wurzburg,  1905. 

Kiister:  Die  Neubildungen  am  Nabel  Erwaehsener  und  ihre  operative  Behandlung.  Langen- 
beck's  Arch.  f.  klin.  Chir.,  1874,  xvi,  234. 

Le  Coniac,  H.  C.  J.:  Cancer  secondaire  de  l'ombilic;  consecutif  aux  tumeurs  malignes  de  l'ap- 
pareil  utero-ovarien.     These  de  Bordeaux,  1898,  No.  19. 

Levadoux,  Michel-Joseph:  Varietes  de  l'ombilic  et  de  ses  annexes.  Fac.  de  Med.  et  de  Pharm. 
de  Toulouse,  1907,  No.  711. 

Neveu:  Contribution  a  l'etude  des  tumeurs  malignes  secondaires  de  l'ombilic,  4°,  These  de  Paris, 
1890,  No.  50. 

Nicaise:   Ombihc.   Dictionnaire  encyclopedique  des  sciences  medicales,  Paris,  2.  ser.,  xv,  1881,  140. 

Quenu  et  Longuet:  Du  cancer  secondaire  de  l'ombilic.     Rev.  de  chir.,  1896,  xvi,  97. 

Runge:  Die  Wundinfectionskrankheiten  der  Neugeborenen.  Die  Krankheiten  der  ersten  Le- 
benstage.     Stuttgart,  1893,  56. 

Spiller,  William  G.,  and  Weisenburg,  T.  H.:  A  Further  Study  of  the  Sensory  Segmental  Zone  of 
the  Umbilicus.     Review  of  Neurology  and  Psychiatry,  Edinb.,  October,  1904,  ii,  680. 


CHAPTER  III. 
UMBILICAL  INFECTIONS  IN  THE  NEW-BORN. 

General  considerations. 
Autopsy  findings. 
Clinical  history. 
Gangrene. 

An  epidemic  of  erysipelas  of  the  abdominal  wall  in  new-born  infants.     Trousseau,  1844. 
An  epidemic  of  erysipelas  and  gangrene  of  the  umbilicus.     Meynet,  1857. 
An  epidemic  of  gangrene  of  the  umbilicus.     Bergeron,  1866. 
Xon -puerperal  erysipelas  of  the  new-born  infant.  Yot,  1873. 
Runge  on  wound  infection  of  the  new-born. 

Mild  disturbances  in  healing  of  the  wound  of  the  umbilicus. 

Omphalitis. 

Gangrene  of  the  umbilicus. 

Diseases  of  the  umbilical  vessels. 

Erysipelas  in  the  first  days  of  life. 
Septic  pyemia  and  infection  of  the  umbilicus  of  the  new-born.     Cohn,  1896. 
Umbilical  sepsis  in  the  new-born  occurring  in  the  nursery  and  child's  hospital,  New  York,  during 

1896.     S.  W.  Lambert. 
Tetanus  in  the  new-born. 

Treatment  of  the  umbilical  cord.     Dickinson's  method. 
Care  of  the  umbilical  stump — a  bacteriologic  study.     Adair. 
Persistent  vitality  of  the  umbilical  cord. 

L'ntil  the  advent  of  asepsis,  myriads  of  children  succumbed  to  umbilical  in- 
fection within  a  few  days  or  a  few  weeks  after  birth.  To  give  a  thorough  digest 
of  the  literature  of  the  subject  here  would  be  out  of  the  question,  and  I  shall  confine 
myself  to  a  consideration  of  the  more  important  articles  bearing  on  the  subject. 

Meynet,  in  his  monograph  published  in  1857,  mentions  the  fact  that  Hippoc- 
rates drew  attention  to  umbilical  infections.  He  also  refers  to  the  writings  of 
Ambroise  Pare,  of  Mauriceau  in  1712,  of  Hamilton  in  1785,  of  Underwood  in  1786, 
and  of  Billard. 

Personally  I  have  derived  much  information  on  the  subject  of  umbilical  infec- 
tions from  the  articles  of  Trousseau  (1844),  Bednar  (1850),  Lorain  (1855),  Meynet 
(1857),  Bergeron  (1866),  Pollak  (1869),  Yot  (1873),  Nicaise  (1881),  Meyer  (1891), 
Runge  (1893),  Gremillon  (1895),  Lambert  (1896),  Cohn  (1896),  Dickinson  (1899), 
Hinsdale  (1899),  Pinkerton  (1900),  Tarnier  and  Budin  (1901),  Wassermann  (1901), 
Porak  (1901),  Maygrier  (1901),  Salge  (1904),  Porak  and  Durante  (1905),  and 
Cumston  (1905). 

Umbilical  infections  may  be  frank  or  masked.  Unmistakable  evidences  of 
inflammation,  such  as  redness,  swelling,  and  discharge,  may  be  present,  or  the  um- 
bilicus may  show  little  or  no  evidence  of  disease,  superficial  healing  occurring  even 
when  an  infectious  process  is  going  on  in  the  underlying  tissues. 

The  umbilical  infections  have  been  designated  as  erysipelas,  puerperal  fever  of 
the  new-born,  or  gangrene,  according  to  the  different  clinical  manifestations  ex- 

70 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  71 

hibited.     They  are  all  due  to  infection  through  the  umbilicus,  and  are  usually 
caused  by  the  same  organisms. 


AUTOPSY  FINDINGS. 

A  careful  study  of  the  autopsy  findings  will  not  only  give  a  clear  idea  of  the 
general  condition,  but  will  also  permit  a  correlation  of  the  various  symptoms  with 
the  avenues  of  infection  concerned.  Infection  may  occur  before  or  at  birth,  but  the 
symptoms  usually  first  appear  at  some  time  between  the  third  and  the  eighteenth 
day  after  birth. 

Appearance  of  the  Umbilicus.  — -In  some  cases  the  umbilicus 
looks  perfect!}'  normal;  in  others  there  is  a  small  opening  from  which  pus  is  seen 
escaping;  or  the  umbilicus  is  represented  by  a  small  ulcerated  area.  The  tissue 
surrounding  the  umbilicus  is  sometimes  soft,  sometimes  red  and  indurated,  and 
occasionally,  by  gently  stroking  the  abdominal  wall  from  the  symphysis  upward, 
one  can  express  a  few  drops  of  pus  from  the  umbilicus.  This  pus  may  be  watery, 
yellowish  or  greenish-yellow  in  color,  the  difference  depending  in  large  measure 
upon  the  pathogenic  organism  present  and  the  duration  of  the  infection. 

When  we  cut  into  the  abdominal  wall,  we  may  find  the  umbilical  vein  and  the 
umbilical  arteries  perfectly  normal,  although  the  surrounding  tissue  is  infiltrated. 

The  umbilical  arteries  and  the  umbilical  vein  as  they  appear  at  birth  are  seen 
in  Fig.  60.  These  vessels  rapidly  atrophy  and  become  impervious  cords,  as  indi- 
cated in  Fig.  61. 

Much  controversy  has  arisen  as  to  the  mode  of  extension  of  the  infection  from 
the  umbilicus.  Some  authors  claim  that  extension  of  the  disease  takes  place  through 
the  umbilical  vein;  others  that  the  arteries  are  responsible  for  the  dissemination 
of  the  purulent  process,  and  still  others  that  the  virus  is  carried  by  the  umbilical 
lymphatics.  A  careful  study  of  the  autopsy  findings  in  numerous  epidemics  clearly 
shows  that  in  some  epidemics  the  vein,  in  other  epidemics  the  arteries,  often  showed 
marked  changes;  in  not  a  few  cases,  however,  the  arteries,  vein,  and  lymphatics  were 
all  implicated.  Practically  it  matters  little  along  which  avenue  the  infection  travels , 
the  chief  thing  to  remember  is  that,  in  the  past,  infection  through  the  umbilicus 
at  birth  has  been  very  frequent  and  has  led  to  most  disastrous  results.  The  um- 
bilical arteries  may  show  no  change,  or  one  or  both  may  contain  partially  or  com- 
pletely organized  clots.  When  it  is  infected,  the  vessel  often  contains  purulent 
material,  and  in  some  cases,  as  a  result  of  the  accumulation  of  pus,  presents  a  fusi- 
form swelling.  The  surrounding  tissue  in  such  cases  often  shpws  a  considerable 
amount  of  edema  or  even  a  purulent  accumulation.  When  the  umbilical  vein  is 
implicated,  pus  may  be  present  in  its  umbilical  portion;  frequently,  however,  it 
contains  here  an  organized  thrombus,  but  in  the  neighborhood  of  the  liver  is  filled 
with  purulent  material. 

Implication  of  the  Various  Organs.  —  Liver.  —  When  the 
umbilical  vein  is  partially  or  completely  filled  with  pus,  it  is  only  natural  that  the 
liver  should  be  implicated.  Sometimes  the  organ  is  a  little  enlarged.  It  may 
contain  small  abscesses,  and  an  acute  inflammation  of  the  veins  of  the  hepatic 
lobules  may  be  noted.  As  a  result  of  the  extension  of  the  infection  a  subphrenic 
abscess  may  develop. 

Lungs.  —  In  some  epidemics  the  lungs  have  shown  marked  changes.     Some- 


72 


THE    UMBILICUS    AND    ITS    DISEASES. 


times  these  took  the  form  of  a  hemorrhagic  pneumonia,  multiple  hemorrhagic 
foci  being  scattered  throughout  the  lung.  In  other  instances  pulmonary  infec- 
tion manifested  itself  by  blackish-green 
patches  of  gangrene,  and  in  some  cases 
scattered  multiple  abscesses  as  large  as 
hazel-nuts  were  found  in  the  lungs.  As 
would  naturally  be  expected,  when 
these  foci  of  consolidation  had  reached 
the  surface  of  the  lung,  a  pleurisy  had 
developed. 

Heart.  —  Only  slight  changes 
are  the  rule,  but  purulent  endocardial 
exudates  have  been  noted  associated 
with  a  purulent  pericarditis.  In  such 
cases  the  blood  from  the  heart  has  been 
found  to  contain  the  organism  respon- 
sible for  the  infection. 

Kidneys.  —  Signs  of  a  paren- 
chymatous nephritis  are  sometimes 
demonstrable. 


Fig.  60. — The  Umbilical  Vessels  about  the  Time 
of  Birth. 
The  umbilical  vein  (a)  conveys  placental  blood  to 
the  fetus.  At  a'  it  is  joined  by  the  portal  vein,  the  com- 
bined trunk  forming  the  ductus  venosus.  The  arrows 
indicate  the  course  of  the  blood  to  the  heart.  The  blood 
passes  from  the  fetus  back  to  the  placenta  through  the 
two  umbilical  arteries  <b  and  V),  only  the  left  of  which  is 
clearly  seen  in  the  picture.  It  was  chiefly  through  the 
umbilical  vein  and  the  umbilical  arteries  that  fatal  in- 
fections of  the  child  were  so  prone  to  occur  in  former 
years.  As  will  be  noted  in  Fig.  61,  these  vessels  become 
obliterated  after  birth. 


Fig.  61. — The  Umbilical  Vessels  in  the  Adult. 
As  soon  as  the  cord  is  tied  the  usefulness  of  the  um- 
bilical arteries  and  of  the  umbilical  vein  is  over,  and  these 
vessels  become  gradually  transformed  into  solid  cords. 
a-a'  represents  the  situation  of  the  obliterated  umbilical 
vein  from  umbilicus  to  portal  vein.  The  ductus  venosus 
has  vanished.  The  location  of  the  left  umbilical  artery  is 
indicated  by  the  dotted  line  b-b'.  The  artery  is  obliter- 
ated from  the  umbilicus  to  the  point  of  origin  of  the  super- 
ior vesical  artery.  The  umbilical  artery  is  the  continua- 
tion of  the  anterior  division  of  the  internal  iliac. 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  73 

Brain.  —  Occasionally  a  meningitis  or  multiple  cerebral  abscesses  are  present. 

Peritoneal  Cavity.  — 'As  a  rule,  there  is  little  or  no  peritonitis 
unless  there  has  been  an  extension  of  the  infection  directly  through  from  the  umbili- 
cus to  the  peritoneum  by  continuity. 

Terminal  Infections.  —  Sometimes  one  of  the  first  signs  may  be  a 
circumscribed  patch  of  erythema  on  the  abdomen,  buttock,  cheek,  eyelid,  or  the 
ear,  or,  in  fact,  on  any  part  of  the  body.  Swelling  in  the  abdominal  wall,  between 
the  umbilicus  and  symphysis,  together  with  swelling  of  the  testicle,  with  or  without 
abscess  formation,  is  not  uncommon. 

Infection  of  various  joints  —  of  the  phalangeal  joints,  wrist, 
elbow,  shoulder,  hip,  knee,  ankle,  and  toes— has  been  noted  in  some  epidemics. 
In  such  cases,  when  the  process  has  been  a  very  rapid  one,  a  terminal  joint  has 
been  found  at  autopsy  to  be  the  only  one  implicated,  whereas  when  the  disease  had 
been  of  some  duration,  the  pathologic  process  had  extended  toward  the  trunk.  In 
some  cases  gangrene  of  the  extremities  had  developed  and  the  joints  showed  dis- 
organization. 

In  the  early  days  bacteriologic  examinations,  of  course,  were  not  made,  and  for- 
tunately at  the  present  time  epidemics  of  umbilical  infection  are  rare.  The  organ- 
isms most  commonly  found  are  Streptococcus,  Staphylococcus  aureus  and  albus, 
and  Bacillus  coli.  Occasionally  Bacillus  pyocyaneus  has  been  noted.  Tetanus 
will  be  discussed  elsewhere. 

CLINICAL  HISTORY. 

As  a  rule,  the  chMd  appears  well  for  several  days  after  birth,  but  then  com- 
mences to  lose  weight.  At  a  period  varying  from  three  to  eighteen  days  it  grows 
restless  and  cries  frequently.  Its  symptoms  strongly  suggest  an  intestinal  upset, 
but  an  examination  of  the  umbilical  region  will  often  clear  up  the  diagnosis.  On 
the  other  hand,  the  umbilicus  may  appear  to  be  perfectly  normal.  As  the  infection 
advances  the  child  will  in  some  instances  develop  a  fatal  pneumonia  or  a  cerebral 
abscess;  or  a  blush  on  the  buttock,  abdomen,  cheek,  or  elsewhere,  or  the  swelling 
of  an  index-finger  or  of  one  of  the  smaller  joints,  may  be  the  first  indication  of  a 
general  infection.  In  such  cases  one  should  always  think  of  the  umbilicus,  and  once 
more  carefully  examine  it,  since  we  know  that  in  the  vast  majority  of  cases  this  is 
the  avenue  through  which  the  infection  occurs. 

There  is  no  definite  set  of  symptoms;  the  clinical  phenomena  will  depend  in  a 
large  measure  upon  the  organ  or  organs  of  the  body  that  are  secondarily  infected. 
If  the  infection  be  of  a  mild  grade,  the  child  may  gradually  recover,  but  where 
"massive  infection"  exists,  great  depression  soon  develops  and  the  patient  speedily 
dies. 

GANGRENE. 

In  the  description  of  the  autopsy  findings  and  clinical  picture  of  umbilical  in- 
fections I  have  purposely  omitted  a  description  of  gangrene  of  the  umbilicus,  pre- 
ferring to  consider  it  separately,  although  it  is  only  another  manifestation  of  an 
umbilical  inflammation  and  is  undoubtedly  caused  by  the  same  organism  or  organ- 
isms. In  the  former  cases  the  local  manifestations  of  the  disease  are  often  over- 
shadowed partly  or  completely  by  those  of  the  general  infection,  whereas  in  cases 
of  gangrene  the  local  condition  receives  the  greater  part  of  the  physician's  attention. 


74  THE    UMBILICUS    AND    ITS    DISEASES. 

Several  days  after  labor  the  skin  in  the  umbilical  region  may  be  slightly  raised 
and  assume  a  yellowish  tinge,  while  the  tissue  surrounding  it  shows  some  reddening 
and  is  indurated.  This  slough  may  come  away,  leaving  a  very  superficial  skin 
wound.  In  many  cases,  however,  the  area  gradually  increases  in  size  and  the  cen- 
tral portion  of  the  slough  becomes  black,  while  along  its  edges  there  appears  a 
narrow,  violet-colored  line — the  line  of  demarcation.  Liquefaction  takes  place, 
and  the  slough  gradually  comes  away  in  pieces . 

If  the  septic  absorption  be  abundant,  the  child  soon  shows  signs  of  toxemia  and 
death  may  rapidly  follow.  Bednar,  in  1852,  when  this  malady  was  relatively  com- 
mon, gave  a  most  vivid  description  of  the  local  conditions  in  the  severe  cases.  He 
spoke  of  the  grayish-black  or  gray  appearance  of  the  umbilical  slough,  and  of  the 
surrounding  zone  of  inflammation,  which  was  often  as  large  as  a  dollar  or  even  as 
the  palm  of  a  hand.  In  such  cases  the  blood-vessels  were  filled  with  dark  thrombi 
or  with  pus.  The  peritoneum  in  the  vicinity  was  often  of  a  dirty  red  color,  markedly 
injected,  and  covered  with  a  plastic,  purulent  exudate;  and  in  some  cases  peritonitis 
developed.  The  general  symptoms  were  naturally  those  of  septic  absorption,  and 
in  the  severe  cases  the  patients  rapidly  succumbed. 

In  rare  instances  the  slough  involves  the  entire  thickness  of  the  abdominal  wall, 
and  when  it  comes  away,  the  intestines  escape  through  the  break.  A  most  inter- 
esting case  of  this  character  was  reported  by  Pollak.  The  patient  (J.  W.)  was 
well  developed,  and,  when  eight  days  old,  weighed  63^  pounds.  When  six  weeks 
old  he  became  very  restless,  and  gangrene  developed  at  the  umbilicus.  The  tissue 
surrounding  the  umbilicus  showed  a  grayish-brown  appearance,  was  soft  and  foul- 
smelling,  and  surrounded  by  a  zone  of  redness.  The  abdomen  was  markedly  dis- 
tended. By  the  end  of  two  days  the  area  of  gangrene  had  become  the  size  of  a 
four-kreuzer  piece.  On  the  fifth  day  the  gangrenous  patch  was  as  large  as  a  thaler, 
and  the  child  refused  the  breast  and  appeared  to  be  dying.  It  revived,  however, 
and  two  days  later  the  abdomen  opened  at  the  umbilicus,  a  loop  of  bowel  pro- 
truded, and  a  perforation  occurred  on  the  following  day.  The  child  died  on  the 
ninth  day  of  the  disease.  By  this  time  the  slough  had  come  away  completely  and 
there  was  a  granulating  surface. 

After  this  brief  discussion  of  the  autopsy  and  clinical  findings  in  cases  of 
umbilical  infection  in  the  new-born,  I  shall  briefly  refer  to  some  of  the  former 
epidemics,  and  describe  somewhat  fully  some  of  their  more  interesting  features, 
as  from  these  one  can  obtain  a  graphic  picture  of  the  unfortunate  conditions  that 
formerly  existed. 


AN  EPIDEMIC  OF  ERYSIPELAS  OF  THE  ABDOMINAL  WALL  IN  NEW-BORN  INFANTS. 

Trousseau,  in  1844,  reported  a  most  disastrous  epidemic  that  occurred  in  the 
months  of  September  and  October,  1843.  As  will  be  noted,  the  erysipelatous  in- 
flammation in  most  of  the  cases  attacked  the  abdominal  wall,  and  in  nearly  all 
instances  there  was  an  infection  of  the  umbilicus  or  of  the  tissues  immediately 
beneath  it. 

In  the  beginning  of  his  article  Trousseau  quotes  Paul  Dubois  as  saying  that 
he  has  never  seen  an  infant  recover  from  erysipelas  during  the  first  month  of  life. 
After  discussing  the  subject  of  erysipelas  in  the  nursing  infant,  he  gives  a  short 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  75 

report  of  a  family  of  19,  including  the  servants,  in  which,  in  the  space  of  six  weeks, 
10  people  were  affected  by  what  appeared  to  be  a  form  of  erysipelas.  He  then  gives 
reports  of  several  cases  in  detail. 

Case  1  .  —  A  boy,  forty  days  old,  developed  signs  of  acute  peritonitis  as- 
sociated with  erysipelas.  He  died  forty  hours  after  the  commencement  of  the 
trouble.     There  was  some  slight  suppuration  at  the  umbilicus. 

Case  2  .  —  When  the  cord  came  away  on  the  fifth  day,  there  remained  at  the 
umbilicus  a  small  area  of  suppuration  with  a  surrounding  zone  of  inflammation. 
The  health  of  the  child  at  that  time,  however,  was  perfectly  good.  Erysipelas 
developed  on  the  twentieth  day  and  the  child  died. 

Case  3  .  —  A  boy,  eight  days  old,  was  affected  with  erysipelas.  Applications 
of  mercurial  ointment  were  made,  but  death  took  place  eight  days  after  the  onset 
of  the  disease.  The  umbilicus  was  the  seat  of  an  abundant  suppuration  and  the 
erysipelas  had  spread  to  the  lower  extremities. 

Case  4  .  —  A  boy,  three  weeks  old,  was  suffering  from  phlegmonous  erysipelas 
and  developed  peritonitis.  Death  took  place  fifteen  days  after  the  onset  of  the 
disease.  The  mother  had  a  grave  puerperal  sepsis.  A  great  many  of  the  women 
had  died  from  puerperal  sepsis  in  the  hospital  about  the  time  of  this  patient's  birth. 
There  was  an  erysipelas  of  the  scrotum  and  of  the  symphysis,  but  the  umbilicus 
showed  no  evidence  of  reddening  or  of  suppuration.  At  autopsy  the  cellular  tissue 
of  the  abdominal  wall  was  found  infiltrated  with  pus;  there  was  a  seropurulent 
fluid  in  the  peritoneum,  and  a  false  membrane  on  the  convex  surface  of  the  liver. 

Trousseau  says  that  these  observations  are  sufficient  to  show  the  extreme 
gravity  of  erysipelas,  in  the  new-born. 


AN  EPIDEMIC  OF  ERYSIPELAS  AND  GANGRENE  OF  THE  UMBILICUS. 

In  reporting  this  epidemic  in  1857,  Meynet  points  out  that  the  disease  was 
readily  divisible  into  two  groups.  In  the  one  an  erysipelatous  inflammation  of  the 
umbilicus  was  the  dominant  symptom;  in  the  other,  ulceration  or  gangrene  of  the 
umbilicus. 

Zinc  chlorid,  in  the  form  of  Canquoin's  paste  (zinc  chlorid  with  wheaten  flour), 
yielded  most  unusual  results  in  this  epidemic. 

Meynet,  in  the  beginning  of  his  article,  draws  attention  to  the  remarks  of 
Pare,  who  regarded  this  malady  as  being  so  grave  that  he  warned  the  surgeon  not 
to  raise  a  hand  for  fear  that  he  might  be  accused  of  causing  the  death  of  the  infant. 
Following  a  lucid  description  of  the  literature  on  the  subject,  he  gives  an  epitome 
of  two  epidemics.  One  began  in  April,  1856,  and  lasted  throughout  May  and  a  part 
of  June.  Early  in  December  of  the  same  year  a  second  epidemic  occurred.  It  was 
one  of  great  severity,  and  lasted  until  January  of  the  following  year.  It  was  similar 
to  the  first  epidemic  in  that  it  ceased  abruptly  as  a  result  of  the  preventive  measures 
which  were  employed. 

Meynet  says  that  after  the  epidemic  and  up  to  the  month  of  March,  when  he 
left  the  service,  they  had  not  had  another  case  in  the  Infirmary  in  Paris.  During 
the  first  epidemic  puerperal  fever  was  not  prevalent,  but  in  the  second  the  umbilical 
infection  in  children  coexisted  with  puerperal  fever  in  women. 

Symptoms. — The  progress  and  the  termination  of  the  disease  were  the  same  in 
both  epidemics. 


76  THE    UMBILICUS    AND    ITS    DISEASES. 

Of  230  infants  received  at  the  Maternity  during  the  month  of  April  and  to  the 
end  of  June  of  1856,  17  were  born  dead,  leaving  213  living  infants.  Of  this  number, 
53  were  attacked — 14  in  the  month  of  April,  25  in  the  month  of  May,  and  14  in  the 
month  of  June.     Thirty-six  of  the  infants  died. 

In  the  second  epidemic,  which  occurred  in  December  and  January,  175  children 
were  delivered  at  the  Maternity:  12  were  born  dead,  163  living.  Of  this  number, 
36  were  attacked  and  8  died.  Meynet  says  nothing  is  more  variable  than  the  period 
of  incubation  in  cases  of  this  disease.  In  some,  symptoms  were  noted  a  few  hours 
after  birth,  in  others  about  the  fourth  or  fifth  day.  Only  rarely  did  they  appear 
after  the  eighth  day.  In  these  last  cases  the  cord  was  black  and  horny,  but  had  not 
separated  from  the  umbilicus. 

In  both  epidemics  he  describes  the  condition  as  nothing  more  than  an  exaggera- 
tion of  an  ordinary  phlegmon,  by  which  he  means  a  moderate  inflammation  of  the 
umbilicus  accompanied  by  the  dropping  off  of  the  cord.  This  inflammation  was 
accompanied  by  ulceration  at  the  base  of  the  cord,  and  a  more  or  less  abundant 
suppuration,  which  retarded  the  dropping  off  of  this  appendage  and  the  cicatriza- 
tion of  the  umbilicus.  Very  soon  this  inflammatory  condition  became  more  in- 
tense, and  the  moderate  inflammation  was  succeeded  by  an  intense  phlegmon. 
In  the  umbilical  region  could  be  noted  a  redness  which  became  more  and  more 
marked;  it  disappeared  upon  pressure,  and  formed  a  circle  around  the  umbilicus. 
At  the  same  time  there  appeared  numerous  circumscribed  swellings.  The  tissue 
around  the  cord  became  ulcerated,  the  margins  were  undermined,  the  ulceration 
extended  deep  downward,  and  the  surface  of  the  depression  was  covered  with  a 
false  membrane,  grayish  white  in  color  and  soft,  from  which  a  bloody,  purulent, 
thick,  fetid  discharge  frequently  exuded.  The  ulceration  increased  in  size.  The 
reddish  zone  also  became  larger  and  took  on  the  color  of  wine-lees.  The  swelling 
became  more  and  more  voluminous  and  was  hard.  In  a  large  number  of  cases  the 
red  areola  was  surrounded  by  a  circle  of  small  vesicles  more  or  less  confluent,  dirty 
white,  round,  not  umbilicated,  and  containing  a  seropurulent  fluid.  Sometimes 
there  was  a  circle  of  erysipelatous  redness,  surrounded  by  numerous  blebs  containing 
a  serosanguineous  fluid.  The  blebs  ruptured  and  exposed  the  skin,  which  readily 
became  involved  in  the  area  of  ulceration. 

The  general  condition  of  the  child  was  not  affected  at  the  beginning,  but  after  a 
time  the  appetite  diminished  and  was  entirely  lost.  The  child  refused  the  breast 
or  any  nourishment  and  cried  continuously.  Its  skin  became  dry  and  withered. 
The  pulse  was  accelerated,  and  the  general  satisfactory  condition  of  the  infant 
was  replaced  by  emaciation.  The  face  was  drawn  from  severe  suffering,  and  the 
nasolabial  folds  became  hollow;  the  tongue  was  dry  and  red  at  the  tip;  in  some 
cases  it  showed  a  thick  coating,  and  occasionally  a  coincident  thrush.  The  abdo- 
men was  distended  and  an  obstinate  constipation,  but  more  frequently  a  diarrhea, 
was  present.  The  case  progressed  with  alarming  rapidity,  and  the  little  infant  often 
died  in  from  thirty-six  to  forty-eight  hours.  Sometimes  the  course  of  the  disease 
was  more  gradual,  but  even  then  a  fatal  termination  was  frequent. 

In  other  cases  the  clinical  course  was  different.  The  cord  was  sometimes  friable 
and  soft;  sometimes  it  was  dry  or  ready  to  drop  as  the  result  of  ulceration.  The 
ulceration  commenced  at  the  margin  of  the  cord,  and  proceeded  from  the  center  to 
the  circumference.  It  occupied  all  the  bottom  of  the  cavity,  and  extended  in  dif- 
ferent directions,  sometimes  destroying  the  attachment  to  the  skin.     It  followed 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  77 

along  the  umbilical  vessels  for  quite  a  distance,  transforming  their  interior  surface 
into  a  vast  focus  of  suppuration.  Sometimes,  on  the  contrary,  it  would  jump  over 
the  cutaneous  external  ring  and  invade  the  abdominal  wall,  spreading  over  a  large 
area.  In  form  it  was  also  irregular;  its  margins  were  sometimes  undermined. 
Most  frequently,  however,  its  surface  was  dull,  of  a  grayish-violet  color,  and  exhaled 
a  gangrenous  odor;  or  it  was  covered  with  a  false  membrane,  which  was  thick,  soft, 
and  very  adherent — the  condition  being  analogous  to  what  is  known  as  "hospital 
gangrene."  In  such  a  case  the  reddish,  circular  area  was  less  circumscribed,  but 
livid  in  color.  The  swelling  was  less  pronounced,  the  pustular  eruption  sometimes 
lacking.  With  an  increase  in  the  severity  of  the  general  symptoms  the  infant 
would  pass  first  into  a  state  of  great  agitation,  but  speedily  into  a  condition  of  col- 
lapse and  death  would  ensue. 

Duration. — The  duration  of  the  disease  was  extremely  variable.  In  certain  cases 
the  suffering  lasted  from  thirty-six  to  forty-eight  hours;  in  others  it  was  prolonged 
to  three  or  four  days,  but  rarely  longer. 

Recovery. — Where  recovery  took  place,  it  was  slow.  The  inflammation  dimin- 
ished in  intensity,  the  ulceration  ceased  to  spread,  the  false  membrane  disappeared 
gradually,  and  granulation  tissue  took  its  place.  The  secretion  gradually  became 
of  a  healthier  nature,  and  the  redness  and  tumefaction  disappeared  little  by  little. 
At  the  same  time  the  general  symptoms  improved,  the  skin  recovered  its  moisture 
and  lost  its  heat;  and  finally,  after  a  more  or  less  prolonged  convalescence,  the 
infant  recovered. 

Meynet  says  that  it  is  easy  to  see  that  the  disease  presents  two  distinct  forms : 
one  is  characterized  by  the  erysipelatous  inflammation  and  by  swelling  of  the 
subcutaneous  cellular  tissue,  with  a  pustular  eruption  and  ulceration.  The  other, 
on  the  contrary,  commences  as  an  ulceration  and  presents  the  appearance  of  hospi- 
tal gangrene.  In  several  cases  he  observed  an  extensive  ulceration  which  always 
occupied  the  center  of  the  surface  of  the  abdomen. 

In  all  of  Meynet's  18  autopsies  the  extent  of  putrefaction  was  carefully  observed. 
Twenty-four  hours  after  death  the  abdominal  walls  showed  a  greenish  tint,  the 
epidermis  was  raised  as  if  undergoing  maceration,  the  reddish  color  of  the  erysipelas 
was  transformed  into  a  blackish  tint,  and  the  abdomen  was  distended.  Beneath 
the  skin  the  cellular  tissue  around  the  umbilicus  was  thickened,  indurated,  more 
dense,  and  more  friable.  This  induration  was  due  to  infiltration  into  the  matrix 
of  the  tissue,  sometimes  with  an  amorphous  plastic  material,  sometimes  with  serum. 

Meynet  says  that  he  never  found  this  process  localized  as  a  distinct  focus,  and 
he  draws  attention  to  the  fact  that  his  results  coincide  with  those  of  Trousseau  and 
Bouchet.  The  thickness  and  induration  became  more  marked  toward  the  margin 
of  the'  umbilical  ring.  At  this  point  the  peritoneum  sometimes  presented  a  cir- 
cumscribed redness,  evidently  clue  to  vascular  arborization,  but  in  only  two  in- 
stances did  Meynet  find  a  well-developed  general  peritonitis. 

In  these  two  cases  the  peritoneum  showed  marked  reddening  and  there  was  a 
false  membrane,  slightly  adherent  to  the  convex  surface  of  the  fiver  and  spleen,  and 
between  the  intestinal  convolutions.  In  the  two  cases  of  general  peritonitis  there 
was  phlebitis  of  the  umbilical  vein.  The  lumen  of  this  vessel  between  the  umbilicus 
and  its  termination  was  filled  with  thick,  whitish  pus;  the  inner  surface  of  the  vein 
was  bright  red,  and  did  not  present  any  ulceration.  The  inflammation  terminated 
abruptly  at  the  ridge  at  the  portal  vein. 


78  THE    UMBILICUS    AND    ITS    DISEASES. 

In  10  cases  there  was  a  partial  peritonitis,  limited  to  the  umbilical  region.  In 
three  instances  Meynet  found  inflammation  of  the  umbilical  arteries,  with  purulent 
material  in  their  lumina.  These  arteries,  which  were  formerly  permeable  from  the 
umbilicus  to  the  bladder,  contained  pus  for  a  distance  of  from  1  to  2  cm.;  in  the 
remaining  portion  of  their  course  they  had  been  obliterated  by  fibrinous  clots. 
In  6  cases  he  found  only  serous  infiltration  and  seropurulent  infiltration  in  the  cellu- 
lar tissue  beneath  the  umbilicus. 

In  a  resume  (p.  24)  he  again  says  there  were  two  distinct  forms  of  the  disease 
noted  in  these  epidemics,  the  one  corresponding  to  erysipelas  of  the  new-born,  and 
characterized  by  its  tendency  to  invade  large  surfaces;  the  other  by  malignant 
ulceration  with  a  tendency  toward  putrefaction  and  gangrene. 

It  may  be  of  interest  to  refer  to  the  notes  on  the  individual  cases  in  these  two 
epidemics. 

The  observations  are  divided  into  two  groups — those  with  erysipelatous  inflam- 
mation and  those  showing  a  marked  tendency  to  ulceration. 

Group  i. 

Case  1  .  —  The  onset  was  marked  on  the  third  day  after  birth  by  an  ery- 
sipelatous inflammation,  followed  by  ulceration.  Death  occurred  three  days  later. 
At  autopsy  there  was  a  moderate  degree  of  peritonitis;  nothing  in  the  umbilical 
vessels. 

Case  2  . —  The  child  was  stricken  on  the  seventh  day  after  birth.  At  the 
beginning  ulceration  was  noted.  The  disease  lasted  three  days  and  was  fatal. 
There  was  general  peritonitis  and  phlebitis  of  the  umbilical  vein. 

Case  3  .  —  The  onset  was  noted  six  days  after  birth.  There  was  an  ery- 
sipelatous inflammation  followed  by  ulceration.  The  actual  cautery  was  used. 
The  child  died  on  the  eighth  day. 

Case  4  .  —  Invasion  on  the  fourth  day;  erysipelatous  inflammation  followed 
by  ulceration.     The  actual  cautery  was  employed.     Death  on  the  seventh  day. 

Case  5  .  —  The  umbilicus  was  invaded  on  the  third  day.  Ulceration  took 
place.  The  actual  cautery  was  used,  but  the  child  died  three  days  after  the  be- 
ginning of  the  inflammation. 

C  a  s  e  6  .  —  Invasion  on  the  second  day.  The  erysipelatous  form  was  noted 
at  the  beginning,  and  later  ulceration.  The  actual  cautery  was  used.  Death  took 
place  on  the  third  day  of  the  disease.  At  autopsy  a  general  peritonitis  and  in- 
flammation of  the  umbilical  vein  were  noted. 

Case  7  .  —  Invasion  on  the  fourth  day.  Erysipelas  of  the  umbilicus  followed 
by  ulceration.  The  actual  cautery  was  ineffectual.  Later  zinc  chlorid  paste  was 
used.     Convalescence  by  the  fifteenth  day. 

Case  8  .  —  Invasion  on  the  third  day.  Ulceration  took  place.  Cauteriza- 
tion with  zinc  chlorid  paste;  the  child  was  convalescent  in  seven  days. 

Case  9  .  —  Invasion  on  the  fifth  day,  with  ulcer  formation.  Zinc  chlorid 
was  employed;  convalescence  by  the  tenth  day. 

Case  10  .  —  Invasion  on  the  second  day.  Erysipelatous  form.  The  wound 
was  cauterized  with  zinc  paste  and  the  child  was  convalescent  by  the  ninth  day  of 
the  disease. 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  79 

Group  2. — In  "Which  Ulceration  was  the  Prominent  Feature. 

Case  1  .  —  Invasion  on  the  third  clay.  Erysipelas  followed  by  ulceration. 
The  wound  was  cauterized  with  zinc  paste.  The  child  was  convalescent  by  the 
eighth  day  of  the  disease. 

C  a  s  e  2  .  —  Invasion  twelve  hours  after  birth.  Erysipelatous  form.  Wound 
cauterized  'with  zinc  paste.     Healing  by  the  ninth  day  of  the  disease. 

Case  3  .  —  Invasion  on  the  fourth  day  and  an  ulcer  formed.  The  wound  was 
cauterized  with  zinc  paste,  and  by  the  ninth  day  the  child  was  convalescent. 

Case  4  .  - —  Invasion  on  the  third  day.  Erysipelas  followed  by  ulceration. 
Cauterization  with  zinc  paste;  the  child  was  convalescent  by  the  eighth  day.  The 
mother  of  this  child  had  puerperal  fever. 

Case  5  .  —  Invasion  on  the  fourth  day.  Erysipelas  with  coexisting  ulcera- 
tion. Cauterization  with  zinc  paste;  by  the  seventh  day  the  child  was  conval- 
escent.    The  mother  had  a  severe,  almost  fatal,  attack  of  puerperal  sepsis. 

Case  6  .  ■ — ■  Invasion  on  the  second  day.  Erysipelas  was  first  noted.  Con- 
valescence had  ensued  by  the  seventh  day  after  the  use  of  zinc  paste. 

Case  7  .  ■ — ■  Invasion  on  the  seventh  day.  There  was  erysipelas  in  the  be- 
ginning, and  the  cord  was  still  adherent.  There  was  ulceration  of  the  outer  part 
of  the  wound,  and  in  this  case  the  child  had  thrush.  Zinc  chlorid  paste  was  em- 
ployed, and  healing  had  taken  place  by  the  tenth  day  after  the  commencement  of 
the  inflammation.     The  mother  was  suffering  from  a  severe  puerperal  infection. 

Case  8  .  —  Invasion  on  the  second  day.  Erysipelas  of  the  umbilicus  was  soon 
followed  by  ulceration.  The  wound  was  cauterized  with  zinc  paste,  but  death 
occurred  on  the  sixth  day  of  the  disease.  The  mother  had  a  moderately  severe 
attack  of  puerperal  infection. 

Case  9  .  —  Invasion  on  the  third  day.  There  was  ulceration  without  ap- 
parent gravity  at  the  beginning;  the  wound  was  cauterized  with  zinc  paste  on  the 
third  day,  but  death  took  place  that  evening. 

Case  10.  —  On  the  third  day  there  was  ulceration  of  a  grave  character;  at 
the  base  of  the  cord  tumefaction  and  redness.  The  actual  cautery  was  used,  and 
four  days  later  zinc  paste  was  applied.     Convalescence  ensued  on  the  seventh  day. 

Case  11. — L.,  born  January  10th.  The  mother  left  the  hospital  in  good 
condition  on  the  eighth  day,  but  the  child  on  the  third  day  after  birth  showed  a 
reddish,  erysipelatous  tumefaction  at  the  umbilicus.  There  was  a  pustular  ery- 
sipelas, with  ulceration  at  the  base  of  the  cord,  but  no  general  symptoms.  The 
wound  was  cauterized  with  zinc  paste.  The  child  recovered  and  was  sent  to  the 
country  on  the  eighth  day. 

Case  12.  —  J.  M.,  born  January  12th.  The  mother  had  mastitis.  The 
child  was  attacked  on  the  third  day  with  erysipelas  and  swelling  at  the  umbilicus. 
The  cord  had  ulcerated  to  some  extent  at  its  base.  It  was  dry  and  adherent.  The 
cord  was  cut,  and  the  cautery  applied  to  the  surfaces.  The  child  was  well  on  the 
twenty-second  of  January. 

Case  13.- —  A.  P.,  born  January  6th.  The  mother  left  the  hospital  on  the 
eighth  day  in  good  condition.  The  child  was  attacked  on  the  fourth  day  with  an 
erysipelatous  condition  at  the  umbilicus,  with  ulceration  of  a  serious  aspect.  Im- 
mediate cauterization  with  zinc  paste;  recovery  by  the  ninth  day. 

Case   14.  —  Charles  V.,   born   January  8th.     Mother   in  good  condition. 


80  THE    UMBILICUS    AND    ITS    DISEASES. 

The  child  was  attacked  on  the  second  day  after  birth.  There  was  erysipelas,  with 
tumefaction  in  the  umbilical  region.  On  the  third  day  ulceration  of  a  severe  nature 
was  noticed  in  the  base  of  the  cord.  The  wound  was  cauterized  with  zinc  paste. 
Convalescence  ensued  on  the  seventh  day  after  the  beginning  of  the  disease. 

Case  15. — -M.S.,  born  January  15th,  was  attacked  on  the  fourth  day  with 
marked  ulceration  of  a  severe  character.  There  was  a  pseudomembrane  with 
elevated  margins,  and  the  wound  showed  an  erysipelatous  character.  It  was 
cauterized  on  January  20th,  and  zinc  paste  applied.  The  child  recovered  and  was 
taken  to  the  country  on  January  27th. 

Case  16.  —  D.,  born  January  21st.  He  was  a  fine,  healthy  child,  but  on 
the  second  day  after  birth  developed  an  erysipelatous  inflammation  of  the  um- 
bilicus. The  cord  was  soft.  On  January  24th  the  ulceration  involved  the  skin 
margins  in  the  umbilical  region.  The  wound  was  cauterized  with  zinc  paste,  and 
he  was  convalescent  by  January  28th. 

Meynet  said  that  he  could  multiply  these  examples,  but  that  those  given  were 
sufficient  to  show  the  gravity  of  the  disease.  He  dwelt  upon  the  efficacy  of  cau- 
terization with  the  chlorid  of  zinc  paste. 


AN  EPIDEMIC  OF  GANGRENE  OF  THE  UMBILICUS. 

Bergeron  discusses  an  epidemic  which  occurred  in  the  Hospital  Necker  in  1865. 
Before  taking  up  the  description  of  his  cases  he  discusses  the  writings  of  Hippoc- 
rates, Ambroise  Pare,  Mauriceau,  Hamilton,  Underwood,  Billard,  Trousseau,  and 
Meynet.  In  speaking  of  his  own  cases  Bergeron  regrets  the  incompleteness  of  the 
pathology.  In  11  cases  he  had  9  autopsies  which  yielded  the  following  results. 
The  portion  of  the  gangrenous  skin  was  black,  moist,  and  situated  at  a  lower  level 
than  that  of  the  surrounding  normal  skin.  It  was  separated  from  the  normal  skin 
by  an  irregular,  slightly  reddish  zone.  Sections  through  the  affected  part  showed 
in  the  center  a  dry  layer,  which  was  easily  detachable  from  the  underlying  tissue 
and  was  held  in  place  by  several  filaments  at  its  periphery.  It  was  2  mm.  in  thick- 
ness, and  its  margins  seemed  to  conceal  an  underlying  part  of  normal  skin.  The 
gangrene  was  always  superficial,  and  penetrated  only  through  the  skin.  The  vessels 
surrounding  the  slough  were  obliterated,  but  in  no  case  was  phlebitis  found  in  the 
umbilical  veins  ox  inflammation  of  the  umbilical  arteries.  One  important  point 
was  that  the  peritoneum  was  always  healthy  except  in  one  case  (Case  3),  in  which 
it  was  injected.  These  observations  differ  from  those  reported  by  Lorain.  In 
the  epidemic  in  1865  Bergeron  did  not  observe  the  second  form  of  the  disease 
noted  in  the  one  reported  by  Meynet. 

Symptoms. — Gangrene  of  the  umbilicus  in  the  beginning  usually  presents  a 
benign  aspect,  the  only  sign  being  a  little  redness  at  the  umbilicus  and  at  the  in- 
guinal folds.  Sometimes  there  are  fretfulness,  a  mild  diarrhea,  and  a  slight  cough. 
The  infant  refuses  the  breast,  and  death  soon  follows,  as  a  rule  peacefully,  without 
convulsions,  but  with  marked  pallor  of  the  skin  everywhere. 

The  local  manifestations  present  certain  special  points  of  interest.  The  lesion 
usually  appears  at  the  umbilicus  before  the  separation  of  the  cord.  There  is  mod- 
erate redness,  or  more  frequently  an  erysipelatous  erythema,  which  invades  usually 
at  the  onset  the  region  which  is  later  occupied  by  the  gangrene.  By  the  following 
day  the  cellular  tissue  has  become  indurated.     Later,  as  a  consequence  of  the  mor- 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  81 

tification  of  the  skin,  there  appears  in  the  inguinal  fold  or  in  a  fold  of  the  skin  sur- 
rounding the  cord  a  yellowish  plaque  which  has  a  tendency  to  extend.  It  is  more 
or  less  bright  in  the  center,  and  moist  at  the  margins.  The  yellowish  color  some- 
times changes  to  black  in  the  center,  and  the  black  usually  extends  to  the  margin 
of  the  lesion  in  the  last  minutes  of  life.  The  skin  surrounding  this  part  is  of  a  light 
violet  color  for  a  distance  of  1  mm.  The  violet  border  follows  all  the  contours  of 
the  slough,  which  is  more  or  less  irregular. 

In  the  more  favorable  cases  this  violet  strip  disintegrates.  The  slough  softens, 
separates  at  the  margins,  and  comes  away  in  small  pieces,  but  is  never  detached  in 
a  single  piece.  It  leaves  behind  it  a  more  or  less  deep  ulceration,  covered  over  with 
granulation  tissue,  which  is  sometimes  very  pale.  The  depth  of  the  ulcer  varies. 
In  certain  cases  it  extends  through  the  entire  thickness  of  the  abdominal  wall,  so 
that  it  would  appear  that  the  intestine  must  come  out.  This,  however,  does  not 
occur.  As  a  matter  of  fact,  the  necrosis  is  only  skin  deep.  In  more  severe  cases, 
which  are  very  rapidly  fatal,  sloughing  takes  place  not  only  at  the  umbilicus  but 
also  in  the  inguinal  fold.  Finally,  occasionally  sloughs  occur  over  the  malleoli, 
the  scapulae,  from  the  ears  or  from  any  region  where  the  skin  is  exposed  to  con- 
tinued rubbing  or  to  humidity. 

In  one  of  Bergeron's  cases  there  was  gangrene  of  the  eyelids  which  occurred 
very  early.  He  says  that  the  abdomen  was  never  distended,  and,  if  there  was 
swelling,  its  point  of  departure  was  chiefly  in  the  abdominal  wall,  not  in  the  cavity 
of  the  abdomen  itself.  The  final  symptoms  were  always  those  of  profound  weak- 
ness. Seeing  the  children  in  the  last  day  of  the  disease,  one  would  have  been  led 
to  think  that  they  had  been  ill  for  a  long  time. 

Diagnosis. — It  'is  hardly  possible  to  confound  gangrene  of  the  umbilicus  with 
any  other  affection.     The  prognosis  is  always  very  grave. 

Etiology. — Bergeron  says  that  gangrene  of  the  umbilicus  was  epidemic,  and  he 
thinks  it  possible  that  the  virus  of  gangrene  belongs  to  the  same  family  as  that 
producing  erysipelas,  puerperal  fever,  and  analogous  conditions.  In  the  beginning 
of  the  year  1865  there  were  in  the  Hospital  Necker  8  cases  of  puerperal  fever  with 
3  deaths.  Several  days  after,  5  children  showed  multiple  abscesses,  and  3  deaths 
followed.  Of  the  5  infants,  4  had  been  with  their  mothers  before  the  puerperal 
fever  appeared.  For  the  greater  part  of  1865  the  sanitary  state  of  the  lying-in 
ward  was  excellent;  only  4  children  had  erysipelas  of  the  cord.  In  the  later 
months  of  this  year,  however,  11  were  attacked  and  only  2  recovered. 

Case  1  .  —  Simple  Erysipelas  of  the  Umbilicus;  Re- 
covery. —  The  girl  was  born  May  26,  1865.  On  June  5th  the  mother  noticed 
a  small  area  of  redness  around  the  umbilicus,  and  the  physician  found  a  small  round 
ulcer  from  which  there  was  a  slight  suppuration.  There  was  a  reddish  thickening 
which  extended  for  several  centimeters  around  the  umbilicus.  The  umbilicus  had 
cicatrized  by  about  the  fifteenth  of  July. 

Case  2.  —  Gangrenous  Erysipelas  of  the  Umbilicus.  — 
Gangrene  of  the  skin  at  various  points.  Death  after  fifteen  days'  illness.  The 
child  was  born  October  23,  1865.  The  mother  nursed  the  child,  but  did  not  have 
much  milk.  On  November  3d  a  little  redness  was  noted  at  the  level  of  the  umbili- 
cus. The  child  was  brought  to  the  physician  on  November  5th.  The  cord  had 
come  away  four  days  before,  and  at  the  point  of  detachment  was  seen  an  elevation 
and  some  swelling.  In  the  umbilical  depression  was  a  sort  of  yellowish,  adherent 
7 


82  THE    UMBILICUS    AND    ITS    DISEASES. 

membrane,  which  in  reality  was  a  slough  of  the  superficial  portions.  The  skin 
was  loosened  and  rolled  up  at  the  margins.  By  the  seventh  the  plaque  at  the 
umbilicus  had  increased  in  size,  and  the  redness  occupied  a  circle  about  2  cm.  in 
diameter.  The  slough  was  yellowish,  6  by  3  mm.,  and  arranged  transversely. 
The  small  patch  in  the  left  inguinal  region  had  a  yellowish  point  about  the  size  of  a 
pin-head.  The  right  inguinal  region  commenced  to  show  a  slight  erythema.  On 
the  ninth  the  umbilicus  was  in  the  same  condition,  but  in  the  left  inguinal 
region  was  a  yellowish  discoloration,  about  4  mm.  in  diameter,  and  in  the  right 
inguinal  region  a  small  superficial  ulcer  without  a  slough.  By  the  tenth  the 
umbilical  lesion  had  increased,  and  the  epidermis  was  implicated  over  an  area  3  cm. 
in  diameter.  The  yellowish  slough  was  1  cm.  in  its  transverse  diameter  and  0.5 
cm.  from  above  downward.  The  slough  in  the  left  inguinal  region  had  increased, 
and  the  area  of  ulceration  of  the  right  inguinal  region  had  a  yellow  discoloration. 
By  the  eleventh  the  gangrenous  ulcer  in  the  right  inguinal  region  had  increased 
in  size,  and  at  the  lower  angle  of  the  scapula  on  the  left  side  could  be  noted  a  red- 
ness, in  the  center  of  which  was  a  small  black  point.  There  was  likewise  redness 
behind  the  right  ear.  The  general  condition  of  the  child  was  not  so  good,  although 
it  continued  to  nurse.  The  umbilical  slough  had  not  increased,  but  in  its  center 
showed  a  little  black  point.  By  November  15  the  child  was  much  weaker.  The 
area  of  induration  at  the  umbilicus  had  increased.  The  slough  in  the  inguinal 
region  had  become  intensified  in  color,  and  the  one  at  the  scapula  showed  a  similar 
change.  The  small  plaques  on  the  ears  were  brownish  and  had  a  gangrenous  odor. 
The  child  died  the  same  evening.  The  autopsy  showed  that  the  abdominal  viscera 
were  normal. 

Case  3.  —  Spontaneous  Multiple  Gangrenous  Ery- 
sipelas, Involving  the  Eyelids.  —  Female  child,  born  on  October 
31.  Two  days  later  the  lids  of  the  left  eye  were  seen  to  be  inflamed  and  presented 
a  marked  yellowish  color.  On  November  5  the  conj  unctival  margins  of  the  eyelids 
were  covered  with  a  false  membrane,  whitish  gray  in  color.  On  the  eighth,  a 
gangrenous  patch  was  noted  at  the  umbilicus,  and  a  livid  redness  at  the  level  of  the 
folds  of  the  buttocks.  The  child  died  on  November  10.  At  autopsy  it  was  found 
that  the  sloughs  were  superficial.     The  one  at  the  umbilicus  was  insignificant. 

Case  4. —  Gangrenous  Erysipelas  of  the  Umbilicus, 
Multiple  Gangrene.- —  Female  infant,  born  November  13,  1865.  It 
must  be  mentioned  that  a  child  suffering  from  a  similar  affection  had  slept  in  the 
next  bed  in  the  same  room  and  had  died  three  days  previously.  On  November 
20  the  mother  brought  the  child  to  the  physician.  The  cord  had  dropped  off 
the  day  before.  The  surrounding  skin  was  red.  Palpation  showed  that  there  was 
induration,  imperfectly  outlined  and  occupying  an  area  around  the  umbilicus. 
The  epidermis  had  disappeared  from  over  an  area  1  cm.  in  diameter,  and  pre- 
sented whitish  or  grayish  patches,  evidently  sloughs.  The  right  inguinal  region 
presented  a  similar  aspect.  By  November  22  the  gangrenous  plaques  had  become 
brownish  and  commenced  to  give  off  an  odor  of  gangrene.  The  child  died  on  No- 
vember 22.  At  autopsy  it  was  found  that  the  slough  hardly  extended  to  the 
bottom  of  the  skin.  The  umbilical  veins  were  normal.  The  umbilical  arteries 
had  been  transformed  into  hard  cords  and  were  surrounded  by  yellowish,  plastic 
lymph.     The  peritoneum  was  not  injected. 

Case   5  .  —  Male  infant,  born  October  27,  1865.     On  the  next  day  a  moderate 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  83 

degree  of  redness  was  noticed  around  the  umbilicus.  By  the  evening,  the  redness 
had  increased  and  had  a  radius  of  2.5  cm.  By  October  29  the  redness  had  not 
increased,  but  the  underlying  cellular  tissue  was  slightly  indurated.  In  the  um- 
bilical fold  was  noted  a  yellowish  plaque,  3  mm.  broad  and  5  mm.  long.  This 
was  moist,  and  its  margins  were  irregular.  By  October  30  the  redness  around  the 
umbilicus  had  increased.  In  the  inner  fold  in  the  groin  a  reddish  plaque  the  size  of 
a  franc  was  noticed,  in  the  center  of  which  was  a  yellowish  point  about  the  size  of 
a  pin-head.  The  child  improved,  but  was  taken  away  by  the  mother  before  it 
was  perfectly  well. 

Case  6.  —  Gangrene;  Erysipelas  of  the  Umbilicus  and 
of  the  Inguinal  Regions.  — ■  Male  infant,  born  November  24,  1865. 
On  November  30,  the  mother  brought  the  child  for  examination.  The  cord 
was  just  about  ready  to  drop  off.  On  lifting  it  with  the  scissors  the  examiner  found 
that  the  tissues  were  grayish  and  formed  a  small  elevation  where  a  slough  with  a 
gangrenous  appearance  had  formed.  There  was  a  slight  redness  of  the  skin  at  the 
fold  of  the  groin  on  the  right  side.  The  child  was  well  nourished.  The  umbilicus 
presented  a  raised  blackish  point,  and  around  it  was  an  ulceration  and  a  yellowish 
depression.  At  the  internal  malleolus  on  the  left  there  was  seen  a  plaque  having 
a  yellowish  center  and  reddish  margins.  The  nurse  said  that  this  had  had  the 
appearance  of  a  boil,  and  that  she  had  opened  it  with  a  needle.  The  child  died  on 
the  fifteenth  of  December.  The  umbilical  ulcer  was  black  and  the  skin  around  it 
greenish. 

Case  7.  —  Spontaneous  Gangrene.  —  A  male  child,  born  No- 
vember 27,  1865,  a*t  a  time  when  cholera  existed  in  the  hospital.  On  December 
2,  the  child  was  brought  for  examination.  The  cord  had  not  come  away  completely, 
but  around  its  base,  and  attached  to  the  skin,  was  a  blackish  point  and  a  noticeable 
elevation.  The  blackish  area  was  surrounded  by  a  yellowish  circle;  there  was  a 
diffuse  redness,  and  the  skin  was  indurated.  There  were  no  general  symptoms,  and 
the  child  was  well  nourished.  By  December  4,  the  tumor  of  the  umbilicus  appeared 
as  a  roundish  nodule,  the  size  of  a  franc  piece.  It  had  a  reddish  circumference  and 
was  yellowish  in  other  portions.  In  its  center  was  a  small  black  slough,  ready  to 
separate.  By  December  11,  the  ulcer  had  practically  healed.  The  child,  how- 
ever, died  on  December  12.  At  autopsy  it  was  found  that  the  ulcer  at  the 
umbilicus  was  insignificant,  and  that  it  had  never  extended  beyond  the  skin.  The 
peritoneum  was  intact,  but  adherent  over  a  large  area.  There  was  no  trace  of 
peritonitis.     The  child  had  died  of  pneumonia. 

Case  8.  —  Multiple.  Gangrene.  —  A  female  child,  two  months  old, 
entered  the  hospital  on  November  27.  About  a  month  before,  the  mother  had 
noticed  a  small  reddish  ulcer  in  the  right  inguinal  fold.  The  umbilical  cicatrix, 
which  had  never  completely  healed,  was  also  the  site  of  a  small  ulcer.  Two  or  three 
days  before  her  entrance  the  skin  in  the  lower  part  of  the  abdomen  had  become 
reddened  and  there  was  some  induration,'  as  in  erysipelas  of  the  umbilicus  of  the 
new-born.  On  her  admission,  at  the  umbilicus  was  a  deep  fold.  At  the  bottom  it 
was  grayish  yellow.  There  was  some  slight  discoloration  at  other  points.  The 
right  inguinal  fold  presented  a  patch  of  the  same  color,  about  1  cm.  in  diameter. 
The  child  died  on  December  1.  The  umbilical  slough  had  reached  a  considerable 
depth.  At  the  bottom,  on  a  level  with  the  umbilical  vein,  was  a  small  mass  of 
purulent  material.      The  vein  itself  was  perfectly  healthy,  free,  without  clots. 


84  THE    UMBILICUS   AND    ITS    DISEASES. 

There  was  no  trace  of  peritonitis.  The  iliac  vein  and  arteries  were  free.  The 
slough  in  the  inguinal  region  was  deeper  than  that  of  the  umbilicus.  The  perito- 
neum was  normal. 

Case  9  .  —  Female  child,  born  January  7,  1866.  About  the  fifth  day  a 
slight  redness  was  noted  at  the  umbilicus,  which  extended  for  a  distance  of  2  cm. 
On  admission  to  the  hospital  it  was  found  that  the  left  eye  was  the  seat  of  a  limpid 
secretion  and  contained  several  yellowish  fiocculi.  The  eyelids  were  a  little  swollen, 
but  not  red.  At  the  umbilicus  there  was  reddening  and  a  little  induration.  The 
cord  had  probably  come  away  only  a  few  days  before.  At  the  site  of  the  umbilical 
cicatrix,  in  a  fold  of  the  skin,  was  an  ulcer,  yellowish  at  the  bottom,  and  about  the 
size  of  a  hemp-seed.  In  the  left  inguinal  fold  was  an  ulcer,  1  cm.  in  diameter,  and 
yellowish  at  it's  bottom.  On  January  19  it  was  noted  that  the  umbilical  ulcer  had 
increased,  and  pus  was  escaping  from  it.  By  January  28,  the  ulcer  at  the  umbili- 
cus had  cicatrized,  but  the  one  in  the  inguinal  region  had  made  considerable  prog- 
ress. Its  margins  were  marked  by  a  fine  black  line,  and  the  center  was  occupied  by 
a  dry  yellowish  plaque.  This  gangrenous  ulcer  was  limited  by  the  inguinal  fold. 
The  anterior  surface  of  the  left  inguinal  fold  was  red,  indurated,  and  denuded  of  its 
epidermis  for  a  distance  of  2  cm.  In  the  center  was  a  yellowish  crust.  The  child 
died  on  January  31.  At  autopsy  it  was  found  that  the  sloughs  were  superficial, 
and  that  they  had  implicated  the  skin  only.  The  underlying  cellular  tissue  was  in- 
filtrated. The  peritoneum  contained  an  abundance  of  fluid  with  a  reddish  tinge. 
There  was  no  false  membrane.     The  intestines  were  healthy. 

Case  10.  — A  female  child,  born  January  19,  1866.  On  January  28  a  red- 
ness was  noted  at  the  umbilicus.  Poultices  were  applied,  but  by  the  next  day  the 
redness  had  increased.  On  January  30  an  ulcer  was  noticed  at  the  umbilicus. 
By  February  4  the  redness  had  diminished  to  the  size  of  a  five-franc  piece.  By 
the  next  day  the  crust  had  disappeared  and  there  was  an  area  of  ulceration  0.5  cm. 
deep.  The  general  condition  was  good.  By  March  1  the  child  was  completely 
well. 

NON-PUERPERAL    ERYSIPELAS    OF    THE    NEW-BORN    INFANT. 

Yot,  in  his  thesis  published  in  1873,  dealt  with  erysipelas  of  the  new-born  and 
described  a  number  of  cases.     In  a  few  instances  the  lesions  started  at  the  umbilicus. 

Case  6  .  —  The  child  was  brought  into  the  hospital  when  it  was  nine  days 
old  with  an  erysipelas  in  the  subumbilical  region.  The  skin  was  of  a  reddish  tint, 
and  there  was  tumefaction  of  the  parts.  The  inflammation  extended  to  the  sym- 
physis and  also  to  the  inner  parts  of  the  thighs.  On  the  right  side  it  extended  to  the 
vertebral  column,  but  on  the  left  it  had  not  gone  beyond  the  fold  of  the  inguinal 
region.  The  umbilical  cicatrix  presented  at  its  center  a  small  surface  of  ulceration 
which  may  have  been  the  point  of  departure  of  the  erysipelas.  From  the  tenth  to 
the  seventeenth  day  the  process  ran  the  usual  course.  On  the  seventeenth  day  an 
abscess  opened  in  the  coccygeal  region.  By  the  twenty-eighth  day  the  child  was 
well. 

Case  9  . —  The  child  was  brought  into  the  hospital  when  it  was  five  days  old. 
An  erysipelatous  inflammation  covered  the  entire  umbilical  region,  the  lower 
portion  of  the  abdominal  wall,  the  lumbar  region,  the  scrotum,  the  penis,  the  right 
side  of  the  thigh,  and  the  right  leg,  except  in  front.  The  parts  were  livid,  and  the 
temperature  was  38.8°  C.     The  child  died  on  the  same  day. 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  85 

Case  11.  — -A  female  infant  was  brought  to  the  hospital  when  it  was  twelve 
days  old.  The  umbilical  cicatrix  was  imperfect  and  showed  a  bloody  discharge. 
There  was  an  erysipelatous  inflammation  over  the  entire  region  below  the  umbilicus 
to  the  thighs  and  legs,  and  a  large  part  of  the  anterior  portion  of  the  thorax  an- 
teriorly. The  temperature  was  37.8°  C;  the  pulse,  184.  The  child  died  the  same 
evening.  The  umbilical  vein  was  found  to  be  normal.  There  was  no  trace  of  peri- 
tonitis.    The  thymus  was  enormous,  and  on  incision  there  escaped  a  purulent  liquid. 

Case  13.  —  A  boy,  born  December  6,  1867,  entered  the  hospital  on  Decem- 
ber 16,  1869,  showing  erysipelas  around  the  umbilicus  and  in  the  suprapubic  region. 
The  scrotum,  penis,  and  the  inner  portions  of  the  thighs  and  legs  were  implicated 
and  there  was  edema  of  the  lower  and  lateral  part  of  the  abdomen.  At  the  umbilicus 
was  an  area  of  sloughing,  20  cm.  in  diameter,  which  was  blackish  in  color.  Pulse, 
144;  temperature,  36.6°  C.  The  child  died  on  December  19.  A  general  peri- 
tonitis was  present.  Under  the  gangrenous  area  the  abdominal  wall  was  adherent 
to  the  large  intestine,  which  had  likewise  become  gangrenous. 

Case  14.  —  The  infant  was  ten  days  old  when  it  was  brought  to  the  hos- 
pital. She  had  thrush.  There  was  an  erythema  and  a  purulent  discharge  from 
the  umbilicus.  The  tissues  around  the  umbilicus  were  covered  with  exfoliated 
epithelium.  There  were  redness  and  tumefaction  below  the  umbilicus,  and  to  the 
right  and  on  the  anterior  surface  of  the  thigh  on  the  right  side.  The  labia  majora 
were  tumefied  and  reddish  in  color.  The  erysipelas  had  apparently  started  from 
the  umbilicus.  The  child  died  on  the  next  day,  the  temperature  being  30.5°  C. 
At  autopsy  small  vegetations  were  found  on  the  mitral  valve.  The  umbilical  vein 
and  arteries  were  filled  with  pus,  and  there  were  signs  of  a  general  peritonitis.  The 
kidneys  contained  coagulated  blood-globules  and  pus.  The  calices  contained  a 
blackish  material  resembling  coffee-grounds,  and  the  papillae  were  of  a  brownish 
color. 

Yot  then  goes  on  to  consider  the  nature  of — (a)  puerperal,  (b)  traumatic  erysipe- 
las. He  discusses  the  symptoms  and  the  complications.  He  concludes  that  there 
are  two  kinds  of  erysipelas  in  the  new-born — one  puerperal,  epidemic,  infectious, 
and  fatal  in  its  course,  and  terminating  as  puerperal  infection  in  women  who  have 
recently  been  confined;  the  other  he  designates  as  an  "inflammation."  He  says 
the  fatality  in  this  group  is  nothing  in  comparison  to  that  in  puerperal  erysipelas. 


RUNGE  ON  WOUND  INFECTIONS   OF  THE  NEW-BORN. 

Runge,  in  his  ''Wound  Infections  of  the  New-born"  (1893),  has  given  us  the 
best  monograph  on  the  subject  that  we  possess.  On  account  of  their  importance 
I  have  given  Runge's  findings  and  his  interpretations  somewhat  fully,  even  at  the 
risk  of  some  repetition,  as  I  am  particularly  anxious  that  the  reader  should  be  cog- 
nizant of  his  views,  although  these  at  times  fail  to  coincide  with  those  of  others  who 
have  had  much  experience  in  the  handling  of  these  cases. 

The  umbilical  wound  is  most  frequently  the  point  of  entry  of  infective  material. 
This  was  proved  in  30  out  of  36  autopsies.  The  pathologic  lochia  contain  a  patho- 
genic organism  and  can  lead  to  very  severe  wound  infection.  The  carrying  of  in- 
fective material  to  a  wound  in  the  new-born  is  almost  entirely  through  contact,  and 
infection  through  the  air  is,  to  say  the  least,  doubtful.  In  the  new-born  the  organ- 
isms most  frequently  found  are  streptococci  and  staphylococci  (Runge,  p.  58). 


86  THE    UMBILICUS   AND    ITS    DISEASES. 

On  page  65  he  says  that  the  portion  of  the  cord  remaining  on  the  child 
beyond  the  point  of  ligature  dies  and  becomes,  as  it  were,  a  foreign  body.  A 
reactive  inflammation  occurs  in  the  skin  of  the  umbilicus.  Death  of  the.  cord 
is  usually  by  mummification;  high  temperature  and  dryness  increase  mummi- 
fication. Moisture  and  exclusion  of  air  hinder  the  extraction  of  the  water  and 
lead  to  a  moist  gangrene.  Simultaneously  with  the  mummification  there  begins 
an  active  inflammation  at  the  umbilicus.  A  few  hours  after  birth  the  capillary 
network  is  found  markedly  distended  and  filled.  Then  the  redness  spreads  over 
the  entire  skin  umbilicus.  This  swells,  and  the  distal  portion  of  the  umbilical 
remains  takes  on  a  yellowish-white  color.  Microscopic  examination  shows  emi- 
grating white  blood-corpuscles  in  abundant  numbers.  They  soften  the  dead  tissue, 
which  is  gradually  loosened  and  falls  off,  leaving  a  granulating  surface.  The  drop- 
ping off  of  the  cord  takes  place,  on  an  average,  on  the  fifth  day.  In  premature  and 
in  weak  children  it  usually  drops  off  later,  because  in  such  cases  the  energy  of  the 
inflammation  is  less  marked.  The  amnion  first  loosens,  then  usually  the  arteries, 
and  finally  the  vein.  The  granulation  surface  of  the  umbilical  wound  after  the  cord 
drops  off  is  frequently  at  a  deeper  level  than  the  abdominal  wall,  because  the  intra- 
peritoneal portion  of  the  umbilical  vessels  has  contracted.  In  those  cases,  however, 
in  which  the  skin  has  been  carried  out  for  a  long  distance  over  the  cord,  the  wound 
lies  above  the  level  of  the  abdomen  and  appears  as  a  definite  umbilical  stump. 
By  retraction  of  the  umbilical  vessels  there  is  gradually  formed  an  upper  and  a 
lower  umbilical  fold,  i.  e.,  a  duplication  of  the  skin  covers  the  deep-lying  umbilical 
wound,  and  further  retraction  of  the  umbilical  vessels  goes  on  simultaneously. 
From  the  day  that  the  cord  drops  off  the  redness  and  swelling  begin  to  recede, 
and  the  healing  process  ends  from  the  twelfth  to  the  fifteenth  day.  The  umbilical 
scar  is  usually  covered  over  with  folds  of  skin.  As  a  result  of  adhesions  of  the 
endothelial  surfaces  the  intra-abdominal  portion  of  the  umbilical  vein  closes  and 
now  forms  the  ligamentum  teres.  The  degree  of  obliteration  of  the  vein  varies 
greatly.  Baumgarten  (quoted  by  Runge)  says  that  the  closure  is  never  complete. 
A  thrombosis  of  the  vein  is  by  most  authors  considered  as  pathologic. 

Runge  says  that  in  the  arteries  the  closure  is  due  to  the  growing  together  of  the 
arterial  walls,  especially  of  the  intima.  Small  thrombotic  plugs  sometimes  exist 
where  the  arteries  bend  in  the  bladder  region. 

Mild  Disturbances  in  Healing  of  the  Wound  of  the 
Umbilicus.  —  Runge  says  (p.  71)  that  the  determination  of  the  line  between 
the  healthy  and  diseased  umbilical  wound  is  difficult.  The  degree  of  reactive  in- 
flammation of  the  umbilicus  depends  on  various  conditions.  With  the  dropping 
off  of  very  succulent  umbilical  cords  the  reaction  is  more  marked  than  in  the  case 
of  those  that  are  somewhat  dry.  In  strong  children  the  inflammatory  reaction 
comes  on  earlier  and  is  more  intense;  more  cells  are  produced  than  in  the  weaker 
ones,  and  in  the  case  of  the  latter  the  cord  drops  off  later. 

Runge  quotes  Widerhofer,  who  says  that  if  the  umbilical  wound  begins  to  be 
moist,  it  secretes  "mucus"  and  pus.  If  the  umbilicus  takes  on  the  character  of  a 
mucous  membrane  there  is  produced  a  condition  termed  by  the  authors  "blen- 
norrhea of  the  umbilicus."  In  these  conditions  it  becomes  difficult  to  determine 
whether  or  not  the  wound  is  infected.  When  the  umbilical  wound  increases  in 
area  and  is  covered  with  a  whitish  and  necrotic  layer,  and  when,  in  addition,  it 
discharges  an  abundance  of  pus  or  purulent  material,  there  can  be  no  doubt  that  an 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  87 

extensive  local  reaction  exists  and  we  have  an  "ulcer  of  the  umbilicus."  Ulcer  of 
the  umbilicus  hardly  ever  exists  if  the  process  remains  localized. 

In  all  his  autopsies  on  infants  who  had  umbilical  ulcer,  Runge  found  either  dis- 
ease of  the  vessels  of  the  umbilicus  or  a  peritonitis  to  account  for  the  death.  If 
neither  of  these  was  present,  he  was  able  to  find  some  other  cause  of  death  inde- 
pendent of  the  ulcer. 

On  page  81  he  takes  up  the  subject  of  omphalitis  and  says  that  it  is  character- 
ized not  so  much  by  marked  inflammation  of  the  umbilicus  as  by  an  infiltration  of 
the  abdominal  wall  around  it. 

Symptoms.  —  In  cases  of  well-marked  omphalitis  the  umbilical  region  is 
markedly  reddened  and  the  umbilicus  projects  conically  outward.  The  area  is 
rarely  cicatrized,  but  usually  appears  as  a  wound  or  a  discolored  ulcer.  The  red- 
ness and  the  inflammation  extend  beyond  the  raised  portion  and  form  a  circle  around 
it.  The  skin  is  tense  and  glistening;  the  folds  have  disappeared.  On  palpation 
a  hard  infiltration  of  the  abdominal  wall  can  be  felt,  and  examination  gives  rise  to  a 
great  deal  of  pain.  The  extent  of  the  infiltration  varies.  It  may  be  limited  to  the 
immediate  vicinity  of  the  umbilicus,  or  the  greater  portion  of  the  abdominal  wall 
may  be  implicated.  It  may  extend  deep  down  and  take  in  the  entire  thickness  of 
the  abdominal  wall  as  far  as  the  peritoneum. 

In  every  case  of  marked  omphalitis  the  general  condition  of  the  child  is  affected. 
It  is  restless,  does  not  take  its  nourishment,  and  has  fever.  There  is  pain  with 
every  movement  of  the  body.  The  legs  are  stiff  and  drawn  up  on  the  lower  ab- 
domen. The  breathing  is  costal  in  type.  The  markedly  engorged  and  dilated 
veins  of  the  stomach  region  sometimes  appear  as  thick,  bluish  strings  seen  through 
the  skin.  The  duration  of  the  disease  depends  on  its  intensity.  It  may  last  several 
days  or  many  weeks. 

Healing  is  the  rule  where  the  phlegmon  is  small.  The  exudate  is  absorbed,  the 
umbilical  wound  cicatrizes,  or  there  may  be  several  small  abscesses  which  break 
outward  and  discharge  a  few  drops  of  pus.  Healing  then  takes  place  in  a  few  days. 
If  inflammation  is  associated  with  the  phlegmon,  it  extends  far  out  in  the  abdomi- 
nal wall  and  healing  is  much  less  likely  to  occur.  The  most  favorable  outcome  is 
obtained  when  there  is  rapid  abscess  formation  before  the  infant  has  been  prostrated 
by  the  fever.  If  the  inflammation  extends  markedly  inward,  death  from  peri- 
tonitis is  likely  to  follow.  If  an  involvement  of  the  umbilical  vessels  is  found  at 
autopsy,  a  general  sepsis  has  existed.  Another  unfavorable  termination  is  in 
gangrene.     This  is  more  apt  to  occur  in  weak  children. 

From  the  foregoing  it  is  seen  that  all  cases  of  wide-spread  omphalitis  are  to  be 
considered  as  dangerous  to  life.  The  younger  the  child,  the  more  unfavorable  the 
prognosis.  Breast-fed  children  have  a  better  chance  than  bottle  children.  Chil- 
dren suffering  from  some  congenital  cachexia — syphilis,  scrofula — and  children  of 
tuberculous  parents  are  predisposed  to  this  disease. 

Gangrene  of  the  Umbilicus. — Runge,  on  page  84,  says  that  gangrene  may  be 
the  consequence  of  a  pathologic  umbilical  wound,  an  ulcer,  or  of  an  omphalitis;  or  it 
may  develop  in  cases  of  severe  general  infection.  Gangrene  as  a  localized  infection  of 
the  umbilicus  does  not  appear  to  be  very  frequent.  Many  authors,  particularly 
Wiclerhofer,  say  that  it  develops  from  a  severe  omphalitis.  Ill-nourished  children 
and  those  born  prematurely  show  a  tendency  toward  the  development  of  local  gan- 
grene.    Severe  diseases  of  the  umbilicus,  such  as  gangrene,  which  were  of  frequent 


88  THE    UMBILICUS    AND    ITS    DISEASES. 

occurrence  formerly,  especially  in  foundling  hospitals,  have  recently  diminished 
greatly.  Fiirth,  in  the  Vienna  Foundling  Hospital,  before  antiseptic  days  saw 
191  infants  suffering  from  gangrene  of  the  umbilicus,  and  169  of  this  number 
died. 

Symptoms.  —  The  wall  of  an  inflammatory  umbilical  wound  becomes 
discolored,  breaks  down,  and  shows  more  or  less  loss  of  substance;  or  there  develops, 
especially  as  a  result  of  an  omphalitis,  a  blister  with  cloudy  contents.  This  rup- 
tures and  a  defect  is  produced.  An  area  of  moist  gangrene  then  appears  and 
extends  rapidly,  sometimes  superficially,  sometimes  penetrating  deeply.  The  cases 
in  which  the  process  goes  inward  are  much  more  dangerous.  The  gangrenous 
area  is  surrounded  by  bright  reddening  of  the  skin  and  reactive  inflammation. 
Gradually  the  gangrenous  portion  becomes  loosened.  It  emits  a  fetid  odor.  Usu- 
ally the  fever  is  not  high,  but  rapid  collapse  is  unfortunately  the  rule.  Where  the 
child's  constitution  is  good  and  the  morbid  process  is  not  wide-spread,  healing  takes 
place  at  this  stage,  the  reactive  inflammation  producing  pus,  which  throws  off  the 
dead  portion,  a  defect  of  greater  or  lesser  extent  being  left,  which  heals  by  granu- 
lation. If  the  child's  strength  has  been  overtaxed,  it  dies  before  the  loosening  of  the 
gangrenous  area  can  occur.  The  average  duration  of  the  disease  in  fatal  cases, 
according  to  Fiirth,  was  5.64  days.  In  several  cases  death  took  place  on  the  second 
day.  "When  the  child  recovered,  the  duration  of  the  disease  at  the  minimum  was 
twelve,  at  the  maximum  thirty-seven  days.  Again,  the  gangrenous  process  may 
spread,  and  in  certain  cases  reported  two-thirds  of  the  abdominal  wall  was  impli- 
cated. Where  the  gangrene  involves  the  whole  thickness  of  the  abdominal  wall, 
intestinal  loops  may  become  adherent  and  perforate,  with  a  resulting  peritonitis  or 
a  fecal  fistula.  Gangrene  may  lead  to  general  sepsis,  in  which  either  the  peritoneum 
is  directly  involved  or  the  septic  material  gains  entrance  through  the  umbilical 
vessels  to  the  general  system. 

Much  more  frequently  there  is  a  second  kind  of  gangrene  affecting  the  umbilicus, 
which  appears  to  be  the  result  of  general  sepsis.  According  to  Widerhofer,  there  is 
a  gangrene  which  follows  cholera  infantum.  In  these  cases  a  localized  necrosis 
occurs,  and  gangrene  is  also  found  in  other  portions  of  the  body,  this  condition 
being  produced  by  emboli.  This  gangrene  is  characterized  by  its  rapid  develop- 
ment and  the  complete  absence  of  reactive  inflammation. 

Often  in  the  course  of  a  few  hours  the  gangrenous  area  reaches  the  size  of  a  dollar. 
It  is  remarkable  that  this  gangrene  occurs  not  only  in  the  first  days  of  life,  but  also 
in  well-nourished  children  several  months  old.  Widerhofer  observed  secondary 
gangrene  of  the  umbilicus  in  children  suffering  from  cholera,  in  the  foundling  hospi- 
tal in  Vienna,  63  times  within  four  years.  In  each  case  death  occurred  very  quickly. 
The  prognosis  in  cases  of  gangrene  of  the  umbilicus,  accompanied  by  cholera 
and  sepsis,  is  absolutely  fatal.  Even  in  those  of  localized  gangrene  the  outcome  is 
doubtful  and  depends  upon  the  resistance  of  the  child.  The  absence  of  inflam- 
matory reddening  is  proof  positive  of  a  fatal  outcome. 

Diseases  of  the  Umbilical  Vessels. 
Runge  says  (p.  88)  that  where  infection  of  the  umbilical  vessels  exists,  the  dis- 
ease first  starts  in  the  perivascular  connective  tissue,  which  becomes  infiltrated  with 
a  serous  fluid  and  shows  evidences  of  edema.     Often  the  process  extends  to  the  ad- 
ventitia,  and  the  vessel  itself  is  involved.     The  inflammatory  infiltration  of  the 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  89 

vessel-wall  causes  a  paresis  of  the  muscularis  and  a  dilatation  of  the  vessels,  or 
gives  rise  to  a  thrombus  which  soon  breaks  clown.  Runge  regards  the  thrombus 
and  its  disintegration  as  a  secondary  manifestation.  He  draws  special  attention 
to  the  fact  that  the  arteritis  and  phlebitis  invariably  start  with  an  inflammation  in 
the  outer  coats  of  the  vessels. 

He  then  quotes  various  authors  who  had  made  experiments,  with  results  agreeing 
with  those  obtained  from  his  own  autopsies.  In  55  cases  from  the  obstetric  clinic 
of  the  Charite  Hospital  in  Berlin,  in  which  autopsies  were  made  on  children  dying 
of  diseases  of  the  umbilicus,  Runge  found  arteritis  in  54  cases — 22  times  in  combina- 
tion with  pneumonia,  16  times  with  other  evident  septic  complications.  Only 
once  could  he  determine  a  phlebitis,  and  in  this  instance  it  was  associated  with  a 
very  intense  arteritis.  As  a  result  of  these  observations  Runge  concludes  that  of 
all  the  fatal  diseases  of  the  umbilicus,  arteritis  is  the  most  frequent  and  most  im- 
portant. He  says  that  this  view  as  to  the  great  fatality  in  infants  from  arteritis  as 
compared  with  phlebitis  has  been  corroborated  by  the  more  recent  observations  of 
Epstein,  Monti,  Birch-Hirschfeld,  and  of  Lomer. 

[Careful  study  of  the  various  epidemics  leads  one  to  conclude  that  in  some  epi- 
demics the  arteries  are  more  frequently  involved,  in  others,  the  veins. — T.  S.  C:] 

On  opening  the  abdomen  and  throwing  outward  the  right  abdominal  wall  Runge 
found  that  the  diseased  arteries  were  to  be  seen  as  thick,  tense,  usually  slightly 
brownish-tinged  cprds,  with  marked  thickening  and  development  of  the  vessels  of 
the  adventitia,  and  that  there  were  also  an  edema  and  infiltration  of  the  surround- 
ing connective  tissue.  In  several  cases  the  arteries  were  implicated  for  their 
entire  length  from  the  umbilicus  to  the  bladder. 

Runge  says  that  frequently  remnants  of  the  umbilical  cord,  after  dropping  off, 
leave  the  umbilical  wound  covered  with  crusts  and  changed  into  an  irregular  ulcer 
with  bays  running  off  from  it.  In  other  cases,  on  the  contrary,  the  wound  shows  a 
perfectly  normal  appearance;  in  fact,  it  may  have  completely  healed  and  yet  an 
intense  arteritis  may  still  exist.  If  the  remnant  of  the  umbilical  cord  is  still  intact, 
it  is  usually  completely  mummified.  In  other  cases  the  cord  gives  out  a  very  foul 
odor.  After  the  softening  of  the  crust  from  the  wound,  one  occasionally  can  see 
the  gaping  umbilical  arteries  and  note  that  they  are  filled  with  pus  or  friable  ma- 
terial. If  an  incision  is  made  through  the  umbilical  wound,  it  is  sometimes  possible 
to  see  with  the  naked  eye  that  the  infiltration  at  its  base  extends  directly  into  the 
diseased  perivascular  connective  tissue;  and  when  the  vessels  are  incised  trans- 
versely, there  is  an  escape  of  yellowish-green  pus  from  them,  or  they  contain  a 
friable,  cheesy  material  mixed  with  blood.  The  surrounding  connective  tissue 
often  presents  a  glistening  appearance. 

An  incision  in  the  long  axis  of  the  arteries,  that  is,  from  the  umbilicus  toward  the 
bladder,  indicates  the  degree  of  extension  of  the  pus,  which  usually  is  associated 
with  an  infiltration  of  the  surrounding  connective  tissue.  Occasionally,  at  the  far 
end  of  the  accumulation  of  pus  in  one  of  the  arteries,  a  reddish-colored  thrombus  is 
found  attached  to  the  vessel-wall.  The  intima  of  the  artery  is  cloudy;  it  has  lost 
its  brilliancy,  and  there  may  be  numerous  unevennesses,  due  to  loss  of  substance 
in  the  vessel-wall.  The  dilatation  of  the  arteries  bears  no  relation  to  the  intensity 
of  the  inflammation  in  the  perivascular  tissue.     On  the  contrary,  the  inflammation 


90  THE    UMBILICUS   AND    ITS    DISEASES. 

of  the  connective  tissue  may  be  enormous,  and  yet  the  lumen  of  the  vessel  may  be 
hardly  large  enough  to  admit  the  passage  of  a  probe. 

Sometimes  the  dilatation  of  the  vessels  is  marked  throughout  their  entire  course ; 
or  again,  at  certain  points,  sac-like  dilatations  occur  in  which  an  abundance  of  pus 
and  caseous  masses  are  found.  In  no  case  of  phlegmonous  infiltration,  however, 
was  he  able  to  follow  the  vessel  as  far  as  the  bladder.  The  extraperitoneal  connec- 
tive tissue  and  iliac  arteries  were  always  free. 

Pneumonia  is  the  most  frequent  complication.  Runge  says  that  in  55 
cases  of  arteritis  it  was  present  22  times.  This  occurred  in  two  forms,  either  as  a 
lobar  pneumonia,  often  complicated  with  a  fibrinous,  serofibrinous,  or  purulent 
pleurisy;  or  there  were  numerous  pea-sized  and  bean-sized  foci  scattered  through- 
out the  lung.  Where  these  reached  the  surface,  there  was  an  accompanying  cir- 
cumscribed pleurisy. 

Runge  found  hyperplasia  of  the  spleen  with  marked  softening  of  the  tis- 
sue, cloudy  swelling  of  the  liver,  parenchymatous  nephritis,  serofibrinous  or  sero- 
purulent  peritonitis,  joint  affections,  periostitis,  and  finally  phlegmonous  inflam- 
mation of  the  subcutaneous  connective  tissue,  with  or  without  pus  formation. 

Erysipelas,  when  observed  as  a  complication,  usually  extends  from  the  umbilical 
wound  outward;  nevertheless,  Runge  says,  it  may  be  primary  in  the  face  or  in  other 
portions  of  the  body. 

Very  frequently  the  bodies  show  a  slight  degree  of  jaundice,  especially  when 
the  death  occurs  between  the  fourth  and  sixth  days,  although  no  direct  connection 
between  the  arteritis  and  the  jaundice  can  be  traced.  In  such  a  case  one  is  dealing 
with  the  so-called  physiologic  icterus  of  the  new-born.  When,  as  happens  more 
rarely,  there  is  an  intense  icterus,  the  complication  is  to  be  attributed  to  a  paren- 
chymatous hepatitis.  Runge  says  that  very  frequently  the  lungs  show  partial 
atelectasis. 

Bacteriologic  investigations  in  cases  of  umbilical  arteritis  have  been  rare. 
Runge  drew  attention  to  those  of  Baginsky,  Meyer,  and  Babes.  The  most  frequent 
cause  of  the  infection  was  found  to  be  a  streptococcus.  In  a  case  described  by  Ba- 
ginsky Streptococcus  pyogenes  was  found  in  the  internal  organs  and  there  was  a 
pyemia  as  a  result  of  inflammation  of  the  umbilical  arteries. 

Runge  gives  a  table  of  55  cases  in  which  an  autopsy  was  performed  and  an  ana- 
tomic diagnosis  of  umbilical  arteritis  was  made  (p.  95).  These  55  cases  of  umbilical 
arteritis  were  taken  from  a  group  of  340  autopsies.  This  means  that  16.1  per  cent, 
of  the  children  who  came  to  autopsy  in  the  gynecologic  clinic  of  the  Charite  Hos- 
pital in  Berlin,  from  1879  to  1882,  showed  inflammation  of  the  umbilical  arteries. 
From  his  table  it  is  seen  that  in  9  cases  arteritis  only  was  found.  This  was  un- 
doubtedly the  cause  of  the  death.  In  16  cases  there  were  complications  (syphilis, 
etc.)  which  apparently  bore  no  relation  to  the  arteritis. 

In  this  group  were  8  cases  in  which  the  complication,  for  example,  hemorrhage 
of  the  brain,  had  been  definitely  the  cause  of  death,  and  the  arteritis  in  5  cases  was 
not  marked.  In  30  cases,  however,  there  were  complications  which  undoubtedly 
were  dependent  upon  the  arteritis.  In  16  cases  these  were  of  a  septic  nature. 
In  one  case,  in  addition  to  the  arteritis,  there  was  an  abscess  of  the  vein  in  its  lower 
portion. 

These  anatomic  results  are  in  opposition  to  the  findings  of  Buhl,  according  to 
whom,  in  cases  of  arteritis,  the  secondary  changes  were  found  in  the  abdominal 


UMBILICAL   INFECTIONS    IN   THE    NEW-BORN.  91 

cavity.  Widerhofer  and  P.  Mtiller  emphasize  the  frequency  of  peritonitis.  This 
complication  Runge  found  only  5  times — in  9  per  cent,  of  the  cases.  He  never  found 
a  perforation  into  the  abdominal  cavity  from  the  diseased  vessels,  as  described  by 
Bednar. 

The  pathogenesis  is  taken  up  on  page  101.  From  the  pathologic  find- 
ings there  can  be  no  doubt  that  umbilical  arteritis  is  a  wound  infection  which  has 
its  point  of  origin  in  the  umbilical  wound  and  which  gives  rise  to  a  general  sepsis. 
Buhl  explains  the  unfavorable  effect  produced  by  puerperal  infection  upon  the 
umbilicus  and  upon  the  changes  in  the  vessel-walls  which  had  already  existed  in 
the  intra-uterine  life.  Runge,  in  discussing  the  possibility  of  the  transference  of 
septic  material  through  the  placenta,  draws  attention  to  the  fact  that  in  the  cases 
of  24  patients  there  was  not  a  mother  who  during  pregnancy  or  during  or  after 
labor  had  had  any  septic  phenomena,  and  in  the  remaining  cases  only  now  and  then 
had  such  symptoms  been  noted. 

Symptoms.  —  A  characteristic  symptomatology  is  wanting  (Runge) .  We 
have  no  clinical  picture  from  which  we  can  make  the  diagnosis  in  the  living  child. 
Usually  the  death  is  unexpected.  The  child  appears  perfectly  normal.  Suddenly 
it  becomes  restless,  refuses  nourishment,  collapses,  and  dies.  An  accident  may  be 
thought  of.  The  autopsy  shows  arteritis.  In  every  case,  however,  the  umbilical 
wound  showed  some  inflammation;  usually  it  was  covered  with  pus,  although  the 
general  condition  of  the  child  was  not  changed.  Then  there  were  sudden  restless- 
ness, crying,  collapse,  and  death.  Since  most  of  these  cases  occur  in  groups,  the 
diagnosis  was  finally  reached  without  any  special  difficulty. 

More  rarely  the  course  of  the  disease  is  prolonged.  In  these  cases  the  indica- 
tions of  a  severe  general  infection  nearly  always  become  evident.  The  children 
have  fever,  loss  of  weight,  increasing  weakness,  and  symptoms  of  collapse.  That 
the  severe  symptoms  are  due  to  disease  of  the  umbilical  vessels  there  is  at  times  no 
evidence,  especially  if,  as  is  frequently  the  case,  the  umbilical  wound  shows  little 
or  no  inflammation  or  has  healed  completely.  If,  on  the  other  hand,  an  ulcer  of  the 
umbilicus  is  present,  a  diagnosis  of  a  general  infection  due  to  an  extension  of  the 
umbilical  disease  is  readily  made.  In  all  cases,  nevertheless,  where  there  is  disease 
of  the  umbilicus,  the  danger  of  inflammation  of  the  arteries  exists.  The  diseased 
organs  do  not  always  present  the  characteristic  picture.  A  lobar  pneumonia  is 
easily  recognized  by  percussion  and  auscultation.  Small  disseminated  foci,  how- 
ever, Runge  was  never  able  to  diagnose.  Where  marked  distention  and  pain  of 
the  abdomen  are  noted,  peritonitis  is  probable,  but,  according  to  Runge's  experi- 
ence, in  the  first  days  of  life  this  is  not  easy  to  diagnose.  Marked  icterus  indicates 
hepatitis,  which  may,  however,  prove  to  be  not  serious.  From  Runge's  table  it  is 
seen  that  the  eldest  child  dying  of  arteritis  was  eighteen  days  old,  the  youngest, 
four  days.     The  largest  number  of  deaths  occurred  on  the  eighth  day. 

Prognosis.  —  No  positive  data  can  be  given.  In  the  case  of  premature 
children,  the  outlook  is  very  grave.  Of  the  55  children  autopsied,  21  had  been  born 
prematurely.  In  50  cases  in  which  inflammation  of  the  umbilical  arteries  was  found, 
21  (42  per  cent)  of  the  infants  were  premature.  Runge  says  that  premature  chil- 
dren who  develop  arteritis  nearly  always  die;  in  the  case  of  a  child  born  at  term, 
the  possibility  of  recovery  exists. 

Etiology.  —  Runge  says  that  contact  of  the  umbilical  wound  with  septic 
material,  but  not  necessarily  only  after  the  cord  has  come  away,  may  be  the  cause 


92  THE    UMBILICUS    AND    ITS    DISEASES. 

of  the  disease.  The  most  virulent  infection  seen  by  Runge  was  in  a  case  in  which 
the  cord  had  not  yet  been  completely  loosened.  The  infection  has  always  been 
most  prevalent  in  lying-in  hospitals  and  foundling  institutions,  and  has  occurred 
in  groups,  whereas  in  private  practice  it  is  rare.  Runge  also  draws  attention  to  the 
fact  that  it  was  often  associated  with  an  epidemic  of  puerperal  fever,  but  maintains 
that  there  may  be  an  epidemic  of  inflammation  of  the  umbilical  vessels  entirely 
independent  of  any  puerperal  infection.  He  had  observed  such  an  epidemic  in  the 
obstetric  department  of  the  Strassburg  Hospital,  in  1876,  and  in  the  obstetrical 
department  of  the  Charite  Hospital  in  1880.  In  both  instances  the  health  of  the 
mothers  was  splendid. 

Prophylaxis.  —  Absolute  cleanliness  is  essential.  If  arteritis  is  once 
established,  little  or  nothing  can  be  done. 

In  discussing  inflammation  of  the  umbilical  vein  Runge  says 
that  Bednar  and  Widerhofer  consider  phlebitis  the  more  important  and  more  fre- 
quent disease,  whereas  recent  authors,  such  as  Epstein,  Birch-Hirschfeld,  and 
others,  dwell  upon  the  preponderance  of  arterial  infection.  Birch-Hirschfeld,  in 
60  autopsies  of  septic  infection  which  had  extended  from  the  umbilicus,  found  phle- 
bitis 11  times,  in  4  instances  a  simple  thrombus  of  the  vein;  whereas  in  32  cases  the 
arteries  alone,  and  in  3  cases  both  arteries  and  vein,  were  simultaneously  affected. 
In  all  his  autopsies  Runge  met  with  phlebitis  only  twice  without  arteritis;  he  re- 
gards phlebitis  of  the  umbilical  vessels  as  a  much  rarer  affection. 

Autopsies  in  which  inflammation  of  the  veins  was 
found  . — Runge  says  that  the  condition  is  usually  similar  to  that  found  where 
arteritis  exists.  The  perivascular  connective  tissue  is  edematous,  the  adventitia 
thickened,  and  the  vessel  tortuous;  there  are  punctiform  hemorrhages.  On  trans- 
verse section  of  the  vessel,  pus,  bloody  pus,  or  pus-like  masses  escape  from  the  lumen. 
The  longitudinal  section  of  the  vessel  shows  an  extension  of  the  disease  into  the 
inner  surface.  The  intima  is  cloudy;  in  places  it  has  been  destroyed,  and  there  are 
deep  ulcers  which  have  eaten  out  large  areas  of  the  vessel-wall.  The  disease  extends 
usually  along  the  entire  length  of  the  vein  from  the  umbilicus  to  the  liver,  which 
may  itself  be  implicated.  According  to  Widerhofer,  Glisson's  capsule  alone  may  be 
implicated;  or  the  portal  vein  and  its  branches  may  show  changes  similar  to  those 
noted  in  the  umbilical  vein.  Most  writers  on  phlebitis  draw  attention  to  the  fact 
that  the  perivascular  tissue  is  first  involved,  and  that  the  vessels  are  invaded 
secondarily.  A  general  septic  condition  is  the  rule,  and  peritonitis  and  parenchy- 
matous hepatitis  are  very  frequent. 

Symptoms.  —  Runge  mentions  fever  and  icterus,  and  agrees  with  Wider- 
hofer that  inspiration  is  short,  expiration  is  prolonged,  and  the  breathing  more 
rapid  than  normal.  The  movements  of  the  thorax  are  scarcely  detectable.  The 
abdominal  musculature  is  nearly  always  contracted.  The  abdomen,  particularly 
in  the  upper  portion,  is  distended.  Pressure  in  the  region  of  the  umbilical  vein 
causes  pain,  which  accounts  for  the  drawing  up  of  the  legs.  The  child  is  restless, 
but  more  or  less  toxic. 

In  conclusion  (p.  116),  Runge  gives  a  full  bibliography  on  diseases  of  the  um- 
bilical vessels. 

Erysipelas  in  the  first  days  of  life  . — Runge  (p.  158)  says  that 
in  the  earlier  days  erysipelas  of  the  new-born  was  wrongly  included  with  puerperal 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  93 

infection  of  the  new-born,  and  that  some  of  the  cases  of  septic  erj'thema  were  classed 
as  instances  of  erysipelas.  Clinically,  there  are  two  forms  of  erysipelas  in  the  new- 
born. One  of  them  is  a  true  erysipelas.  In  the  table  of  children  dying  from  um- 
bilical arteritis,  erysipelas  was  noted  twice — once  on  the  abdomen  and  once  on  the 
face.  According  to  Gusserow,  the  course  of  such  a  double  infection — erysipelas 
associated  with  septic  inflammation — is  always  fatal.  The  second  form  of  erysipelas 
attacks  children  that  have  heretofore  been  healthy.  The  infection  spreads  partly 
from  the  umbilical  wound  and  partly  from  some  slight  injury  of  the  genitals. 
Erysipelas  in  the  new-born  almost  always  causes  death. 


SEPTIC  PYEMIA  AND  INFECTION  OF  THE  UMBILICUS  OF  THE  NEW-BORN. 

Cohn,  writing  in  1896,  says  that  although  these  diseases  are  not  so  common  as 
formerly,  they  are  not  rare.     He  then  goes  on  to  report  two  interesting  cases: 

Case  1.  —  Umbilical  Phlebitis;  Phlegmon  of  the  Fore- 
arm; Spontaneous  Rupture  of  the  Purulent  Phlegmon 
Through  the  Umbilicus;  Recover  3'.  —  A.  S.  was  brought  to 
the  clinic  when  fourteen  days  old.  On  the  second  day  the  umbilical  cord  had  been 
tied  for  a  second  time  by  the  midwife  because  it  was  thought  to  be  too  large.  On 
the  fourth  day  it  came  away  during  the  bath.  About  the  thirteenth  day  the  mother 
noticed  that  the  left  hand  of  the  child  was  red  and  swollen.  Local  applications 
were  made,  but  the  swelling  did  not  diminish.  By  the  afternoon  it  had  reached  to 
the  forearm,  and  by  evening  to  the  elbow,  and  early  the  next  day  up  the  arm.  The 
child  had  fever,  was  very  restless,  and  cried  a  great  deal,  especially  on  being  dis- 
turbed. On  admission  it  was  found  that  the  umbilicus  was  drawn  in  and  in  the 
depression  was  some  slight  secretion.  The  forearm  was  markedly  reddened  and 
swollen,  and  any  movement  caused  great  pain.  Swelling  and  fluctuation  were  no- 
ticeable in  the  neighborhood  of  the  wrist-joint.  The  back  of  the  hand  was  ede- 
matous and  swollen.  At  operation  not  much  pus  was  evacuated,  but  the  tissue 
of  the  forearm  showed  infiltration,  which  reached  to  the  hand,  so  that  it  was  neces- 
sary to  lay  open  the  musculature  of  the  thumb  and  of  the  ball  of  the  little  finger. 
Further  operations  were  subsequently  necessary.  Later  on  the  mother  noticed  to 
her  surprise  that  the  umbilicus  was  fully  a  "segment  of  a  finger"  high,  and  that  it 
was  bluish  red;  that  there  was  swelling  for  at  least  5  cm.  in  the  neighborhood  of  the 
umbilicus,  and  that  it  was  edematous  and  painful.  Pressure  caused  a  discharge 
from  the  umbilicus  of  a  thin,  fluid  pus.  Following  the  introduction  of  a  probe  the 
escape  of  pus  was  much  more  free.  The  probe  could  be  carried  upward  4  cm.  and 
beneath  the  abdominal  muscles.  From  the  mother  it  was  now  learned  that  the 
umbilicus  had  up  to  this  time  always  shown  a  little  purulent  discharge.  At  the 
end  of  a  year  the  child  was  well  and  the  umbilicus  was  well  drawn  in. 

Case  2 .  —  Umbilical  Phlebitis;  Phlegmonous  Ery- 
sipelas; Suppurative  Peritonitis;  Death.  —  Paul  B.  The 
cord  came  away  on  the  fifth  day,  but  as  a  piece,  2  cm.  long,  remained  attached  to 
the  abdomen,  it  was  tied  off  by  the  midwife  with  a  white  thread.  After  this  the 
wound  is  said  to  have  suppurated  for  about  six  days  and  then  remained  dry.  Five 
days  later,  over  the  ankle-joint  of  the  left  leg  definite  swelling  and  redness  were 
noted.  Two  days  later  redness  was  noted  on  the  right  leg;  still  two  clays  later  the 
scrotum  and  the  surrounding  parts  were  swollen,  and  it  was  with  difficulty  that  the 


94  THE    UMBILICUS    AND    ITS    DISEASES. 

child  could  urinate.  On  the  following  day  it  was  found  necessary  to  open  the  left 
ankle.  The  redness  and  swelling  over  the  back  and  the  extremities  had  extended. 
Four  days  later  vomiting  began.  The  abdomen  was  distended,  being  as  hard  as  a 
board.  The  abdominal  walls  were  glistening,  and  the  veins  were  markedly  dis- 
tended. Any  movement  of  the  body  occasioned  pain.  The  umbilicus  was  closed, 
dry,  and  not  prominent.  The  buttocks  were  covered  with  an  erysipelatous  in- 
flammation, chiefly  noticeable  along  its  advancing  margin.  This  extended  to  the 
nipple  line  and  nearly  to  the  scapula.  Along  the  lower  border  of  the  scrotum  was 
an  ulceration  the  size  of  a  five-pfennig  piece,  covered  with  yellow,  smeary  material. 
The  child  died. 

At  the  autopsy,  which  was  performed  the  same  day,  the  umbilical  wound  was 
found  healed.  There  was  edema  of  the  abdominal  wall.  The  peritoneum  was 
thickened  and  showed  a  purulent  inflammation.  When  the  abdominal  cavity  was 
opened,  there  escaped  a  yellowish,  clear  fluid,  which  contained  white  flocculi,  sero- 
purulent  in  character.  From  a  quarter  to  half  a  liter  of  fluid  lay  between  the  dis- 
tended intestinal  loops.  The  umbilical  vein  was  found  markedly  distended, 
especially  in  the  neighborhood  of  the  liver,  where  it  was  almost  as  thick  as  the 
little  finger.  It  contained  yellow  pus.  The  purulent  contents  of  the  vein  could 
be  followed  to  the  portal  vein,  and  on  section  to  the  liver.  Pus  escaped  from 
a  large  branch  of  the  portal  vein.  The  liver  was  enlarged  and  showed  cloudiness. 
Cocci  in  chains  were  detected. 

Cohn  then  refers  to  several  other  epidemics,  and  quotes  Epstein,  who  wrote  in 
1888  from  the  Foundling  Asylum  in  Prague.  This  author  says  that  the  mortality 
was  30  per  cent  in  preantiseptic  days,  and  that  it  had  dropped  to  5  per  cent,  but 
that,  from  January,  1887,  to  April  30,  1888,  out  of  116  children  that  had  died  from 
a  total  of  1816  that  had  been  received,  in  not  less  than  36  (31  per  cent)  the  histologic 
diagnoses  showed  that  the  sepsis  had  started  as  an  inflammatory  infection  of  the 
umbilicus  and  of  the  umbilical  vessels.  Miller,  quoted  also  by  Cohn,  found  that 
in  the  Moscow  Foundling  House  from  about  6  to  8  per  cent  of  the  children  died  of  a 
purulent  process,  the  great  majority  of  these  septic  infections  emanating  from  the 
umbilicus.  From  the  Innsbruck  Clinic,  Ehrendorfer  reported  1764  cases  occurring 
from  May  5,  1888,  to  the  end  of  April,  1892.  Of  these  infants,  95  died  and  81  came 
to  autopsy.  Of  this  number,  16 — about  20  per  cent  of  the  cases  that  came  to 
autopsy — showed  infection  of  the  umbilical  arteries  or  veins. 

Eross,  also  quoted  by  Cohn,  found  that,  out  of  1000  infants  born  in  the  Obstet- 
ric Clinic  in  Budapest,  in  over  320  (32  per  cent)  the  mummification  of  the  umbili- 
cus took  place  normally.  In  680  (68  per  cent)  there  were  not  only  deviations  from 
the  normal,  but  often  marked  pathologic  changes  at  the  umbilicus,  such  as  in- 
flammation and  the  formation  of  ulcers.  Routine  temperature  observations  further 
demonstrated  that,  of  the  680  infants,  220  had  a  rise  of  temperature,  and  5  of 
these  died  during  their  stay  in  the  clinic. 

Cohn  speaks  of  the  use  of  alum,  of  tannin,  and  of  sugar,  and  comes  to  the  con- 
clusion, as  a  result  of  various  investigations,  that  it  is  wiser  to  avoid  bathing  the 
child  after  the  first  day,  until  the  cord  has  come  away.  He  speaks  of  treating  the 
cord  by  the  dry  method,  not  even  allowing  it  to  be  exposed  to  the  air. 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  95 

UMBILICAL  SEPSIS  IN  THE  NEW-BORN  OCCURRING  AT  THE  NURSERY  AND  CHILD'S 
HOSPITAL,  NEW  YORK,  DURING  1896. 

S.  W.  Lambert,  in  his  interesting  description  of  an  epidemic  occurring  in  New 
York,  says  that  the  obstetric  department  of  the  Nursery  and  Child's  Hospital  lost 
five  babies  from  umbilical  sepsis  during  1896.  The  epidemic  occurred  in  July, 
August,  and  September.  During  the  three  months  there  were  40  children  born,  and 
of  these,  only  4  remained  free  from  fever;  the  remainder  developed  a  temperature 
of  100°  F.  or  over.  The  real  epidemic  was  characterized  by  a  peculiar  skin  erup- 
tion and  was  coincident  with  the  delivery  in  the  ward  of  a  woman  who  became  very 
ill  with  a  virulent  sepsis  from  which  she  died.     I  shall  briefly  outline  the  fatal  cases. 

Case  1  .  —  The  child  lost  weight  from  the  date  of  birth  to  the  fifth  day  and 
died  on  the  twenty-second  day.  In  this  case  the  right  foot  became  swollen  and  the 
heel  and  toes  gangrenous.  At  autopsy  the  umbilicus  appeared  to  be  normal,  but 
in  the  umbilical  vein  there  was  a  fusiform  clot,  three  inches  in  length,  also  small 
clots  in  the  arteries,  and  beneath  them  small  collections  of  pus  in  the  tissues.  Cul- 
tures from  the  pus  in  the  tissues  gave  staphylococci. 

C  a  s  e  2  .  • —  This  child  was  born  after  a  dry  labor  of  fifty-eight  hours,  lost  17 
ounces  in  three  days,  and  died  on  the  twentieth  day.  At  autopsy,  the  umbilical 
vein  appeared  normal,  but  the  right  hypogastric  artery  was  swollen  and  reddish  for 
three-fourths  of  an  inch  from  the  umbilicus.  On  manipulation  grayish-brown, 
grumous  pus  escaped  from  the  umbilicus.  A  probe  was  readily  introduced  into  the 
artery.  The  pus  yielded  pure  cultures  of  Staphylococcus  aureus  and  albus.  The 
cord  was  still  adherent. 

Case  3  .  — *The  infant  had  lost  14  ounces  in  weight  by  the  fourth  day,  and 
was  jaundiced  during  the  first  week.  At  autopsy  there  was  noted  a  fusiform  swell- 
ing of  the  right  hypogastric  artery  just  below  the  umbilicus.  This  contained  bloody 
pus.  The  left  artery  and  the  umbilical  vein  were  normal.  The  cord  was  attached 
to  the  umbilicus,  and  at  its  base  was  an  excoriation  extending  an  inch  in  each  direc- 
tion.    No  cultures  were  made. 

Case  4  .  —  The  labor  was  normal.  The  child  had  lost  12  ounces  by  the  fourth 
day  and  died  on  the  twelfth  day.  A  pemphigoid  eruption  was  noted  on  the  neck 
on  the  fourth  day,  and  spread  rapidly  over  the  shoulders.  The  cord  came  away  on 
the  sixth  day.  At  autopsy  the  umbilicus,  when  opened,  was  found  to  contain  a  dis- 
colored, yellow,  liquid  mass,  which  seemed  to  extend  through  into  the  artery  and  vein. 

Case  5  .  —  The  cord  came  away  on  the  tenth  day.  The  umbilicus  contained 
pus.     There  was  no  autopsy. 

TETANUS  IN  THE  NEW-BORN. 

Prior  to  the  aseptic  treatment  of  the  cord,  children  often  developed  tetanus 
through  the  umbilicus.  The  cases  usually  occurred  singly,  but  now  and  then  there 
was  an  epidemic  with  a  high  mortality.  At  the  present  time  umbilical  infection 
with  this  organism  is  rare,  except  in  countries  in  which  the  natives  have  no  medical 
attention  and  are  accustomed  to  treat  the  cord  in  a  very  crude  and  primitive 
fashion. 

Runge's  description  of  the  symptoms  of  tetanus  in  the  new-born  is  so  lucid 
that  I  will  quote  it  in  detail: 

On  page  145  he  says:  "In  this  vicinity  it  is  not  frequent,  in  fact  in  the  obstetric 


96  THE    UMBILICUS    AND    ITS    DISEASES. 

institutions,  since  the  introduction  of  antisepsis,  it  has  become  very  rare.  On  the 
other  hand,  in  some  places  tetanus  is  endemic.  The  new-born  in  the  tropics,  and 
especially  children  of  the  colored  races,  are  frequently  attacked  by  it.  The  prob- 
ability is  that  this  infection  is  due  to  a  lack  of  cleanliness."  On  page  148  he  says 
that,  within  two  years,  according  to  Keber,  in  the  practice  of  one  midwife  who  cared 
for  308  infants,  99  died  of  tetanus.     This  was  in  the  years  1863  to  1865. 

Symptoms.  — "The  trouble  manifests  itself  suddenly.  The  lower  jaw 
remains  stiff,  and  is  kept  only  a  short  distance  from  the  upper.  The  muscles  are 
so  strongly  contracted  that  it  is  impossible  to  open  the  mouth.  At  the  same  time 
there  is  a  change  in  the  countenance.  The  forehead  is  markedly  furrowed,  the 
space  between  the  lids  smaller,  the  lips  are  pressed  together  and  often  drawn  up 
in  a  snout-like  fashion,  showing  radiating  folds.  There  is  marked  drawing  together 
of  the  musculature  of  the  back,  bringing  the  head  backward  and  producing  an 
opisthotonos.  Owing  to  contraction  of  the  abdominal  muscles  the  abdomen  be- 
comes as  hard  as  a  board,  and  is  usually  deeply  drawn  in.  The  extremities  are 
affected  also  by  the  contraction,  but  to  a  less  extent.  The  arms  are  drawn  up,  the 
hands  clenched  to  form  fists.  The  legs  are  stretched,  the  toes  abducted.  In  well- 
marked  cases  the  body  is  as  stiff  as  an  iron  plank  (Soltmann) .  One  can  grasp  the 
child  and  lift  it  up  as  one  would  lift  a  statue.  The  commencement  of  the  tetanic 
convulsion,  especially  where  the  disease  is  advanced,  may  be  brought  about  by  any 
disturbance  of  the  child,  by  an  attempt  at  nursing,  by  a  change  in  its  position, 
or  by  a  strong  current  of  air.  Later  the  intervals  between  attacks  become  shorter 
and  shorter,  and  finally  the  contraction  is  continuous. 

"The  respiratory  muscles  are  usually  not  markedly  involved  at  first.  As  the 
disease  progresses,  however,  dyspnea  develops;  the  child  becomes  cyanotic,  and, 
owing  to  contraction  of  the  muscles  of  the  throat,  swallowing  becomes  impossible. 
The  laryngeal  muscles  are  often  affected,  so  that  the  cries  of  the  child  are  interrupted 
or  it  cannot  give  any  vocal  evidence  of  its  great  pain. 

"The  pulse-rate  is  usually  increased,  from  160  to  200;  the  temperature  is  ele- 
vated, and  may  reach  41°  to  42°  C.  Defecation  and  urination  are  only  rarely  much 
disturbed.  The  course  of  the  disease  is  usually  unfavorable.  The  attacks  increase 
in  number,  and  finally  the  intermissions  between  them  become  very  short.  A 
severe  grade  of  cyanosis  supervenes,  and  as  a  result  of  the  impossibility  to  take 
nourishment  there  is  marked  emaciation.  Death  may  take  place  on  the  first  or 
second  day,  but  it  usually  occurs  between  the  fifth  and  sixth  days.  Recovery  is 
rare.  In  favorable  cases  the  attacks  gradually  diminish  in  strength  and  in  duration. 
Occasionally  bones  are  broken,  muscles  are  torn,  and  paralysis  of  individual  muscles 
occurs." 

REMARKS. 

After  reading  the  records  of  the  appalling  epidemics  of  fatal  umbilical  infections 
that  occurred  from  the  earliest  days  of  medicine  up  to  the  era  of  asepsis,  one  in- 
stinctively turns  back  to  those  two  modest  scientific  investigators,  Louis  Pasteur 
and  Joseph  Lister.  More  than  any  others,  these  two  have  been  the  direct  means  of 
saving  the  lives  of  thousands  upon  thousands  of  new-born  babes,  and  have  in  a  large 
measure  removed  the  nightmare  of  childbed  fever. 

The  above  detailed  report  of  the  records  of  so  many  epidemics  may  seem  some- 
what superfluous,  in  view  of  the  fact  that  in  the  future  we  shall,  fortunately,  have 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  97 

little  to  fear  from  this  quarter.  Such  reports,  however,  will  serve  to  emphasize  the 
powerlessness  of  the  older  physicians  in  the  face  of  such  emergencies.  Moreover, 
it  is  clearly  evident  that  even  at  the  present  time  an  insidious  umbilical  infection 
occasionally  exists  and  that  it  may  lead  to  the  child's  death,  before  the  original 
focus  of  infection  has  ever  been  suspected.  In  every  instance  of  ill- 
ness in  a  new-born  infant  it  should  always  be  the 
rule    to    inspect    and,    if   necessary,    reinspect   the    navel. 


TREATMENT  OF  THE  UMBILICAL  CORD. 

This  subject  is  dealt  with  so  fully  and  satisfactorily  in  the  text-books  on  ob- 
stetrics that  it  would  be  superfluous  to  discuss  it  in  any  detail.  It  will  not  be  out 
of  place,  however,  to  consider  a  very  interesting  paper  by  R.  L.  Dickinson,*  en- 
titled, "Is  a  Sloughing  Process  at  the  Child's  Navel  Consistent  with  Asepsis  in 
Childbed?"  Although  the  article  was  published  in  1899,  it  has  not  received  the 
attention  it  merits.  "This  paper  is  a  plea  for  the  application,  in  amputating  the 
cord,  of  the  surgical  principles  that  govern  other  amputations.  The  following 
principles  are  directly  opposed  to  the  prevailing  practice,  but  would  seem  to  bear 
upon  the  matter: 

"  (1)  Mass  ligature  should  be  avoided.  Hemorrhage  follows  the  present  method 
occasionally,  because  shrinkage  of  the  gelatin  loosens  the  seizure.  Ligatures  belong 
on  bared  vessels. 

"  (2)  A  hernial  opening  should  not  be  closed  by  a  granulation  scar.  Primary 
union  is  readily  substituted. 

"  (3)  If  the  location  of  the  future  line  of  demarcation  is  known,  removal  should 
be  practised  at  or  beyond  that  point.  In  the  case  of  the  funis,  one  knows  where  the 
line  of  separation  is  to  be. 

"  (4)  That  form  of  operation  should  be  chosen  which  will  do  away  with  sloughing 
or  pus  production.  Prevention  of  suppuration,  of  putrefaction  in  the  stump,  and 
of  systemic  infection  has  been  attempted  by  means  of  numberless  devices  and  dress- 
ings, spread  through  a  voluminous  literature  of  failure.  Removal  alone  is  preven- 
tion. The  obstetric  nurse  will  then  no  longer  go  from  a  pus  dressing  on  the  baby's 
abdomen  to  the  fissured  nipple,  the  perineal  wound,  the  catheter,  or,  in  small  ma- 
ternities, to  the  vulva  of  the  woman  in  labor. 

"And,  conversely,  septic  maternal  discharges  will  cease  to  endanger  the  child's 
open  wound. 

"To  frankly  sever  the  cord  at  the  skin  margin,  with  ligature  of  the  vessels  or 
suture,  one  or  both,  brings  about  safe,  clean,  prompt  healing.  Even  the  pressure 
of  a  pad  and  an  adhesive  strap  may  suffice.  Thereby  the  navel  of  the  second  day 
looks  like  the  navel  of  the  tenth  or  fifteenth  day  under  other  methods.  After  suc- 
ceeding with  many  cases  of  complete  primary  amputation,  the  writer  found  that 
Flagg  had  recently  published  the  method  in  part." 

Dickinson  then  gives  a  most  painstaking  and  thorough  review  of  the  literature, 
draws  attention  to  the  large  number  of  children  that  die  of  a  sepsis  starting  from  the 
umbilicus,  when  the  family  physician,  even  after  the  death  of  the  child,  is  totally 
unaware  that  the  infection  commenced  in  the  umbilicus  or  that  the  death  was  due 
to  sepsis. 

*  Dickinson,  R.  L.:  Amer.  Jour.  Obstet.,  1899,  xl,  14. 


98 


THE    UMBILICUS    AND    ITS    DISEASES. 


He  then  describes  his  mode  of  amputating  the  cord:  "Elaborate  detail  con- 
cerning the  various  methods  classified  above  is  hardly  necessary.  A  typical  example 
of  each  class  may  be  given : 

"Preliminaries  to  All  Three  Methods.—  As  the  child's 
trunk  makes  its  exit,  a  sterile  or  clean  towel  is  so  applied  to  the  abdomen  that  the 
cord  and  the  umbilical  region  make  no  contacts  once  outside  the  grasp  of  the  vulvar 
ring.  The  trunk  is  wrapped  in  the  towel  as  the  baby  is  laid  down  or  resuscitated. 
As  soon  as  pulsation  grows  feeble,  the  cord  is  clamped  beyond  the  towel  between 
two  Keith  forceps  and  cut.  Artery  clamps  have  an  insufficient  bite  for  large  cords. 
The  child  is  laid  aside  until  the  placental  stage  is  completed  and  the  perineum  has 
received  attention. 

"The  material  is  prepared.  The  choice  of  method  is  made,  and  now  the  child 
is  laid  on  a  table.  A  towel  is  wound  about  its  arms,  and  another  about  its  legs,  to 
keep  it  quiet  and  to  insure  a  clean  field.  The  towel  is  unwrapped  from  about  the 
abdomen.     The  nurse  draws  the  cord  out  by  the  forceps  that  has  been  placed  six 


Fig.  1 


Fig.  62. — (After  Dickinson.) 

Fig.  1. — The  scissors  free  the  cord  from  the  skin, 
and  then  push  up  the  sheath  and  the  jelly. 

Fig.  2. — The  trousers-leg  slipped  upward  with  the 
gelatin,  exposing  the  vessels.  The  ligature  is  placed 
as  low  as  possible. 

Fig.  3. — After  ligature  and  cutting  away. 

Fig.  4. — The  stump  rolls  in  at  once. 


Fig.  5 


Fig.  6. 


Fig.  63. — Method  of  Teeating  the  Umbilical  Stump 
at  Birth.     (After  Dickinson.) 

Fig.  5. — Removal  of  cord  at  one  snip  of  the  scis- 
sors, the  fingers  holding  the  stump,  as  shown  in  the 
next  cut. 

Fig.  6. — The  fingers  still  hold  the  stump  while 
suturing. 

Fig.  7. — One  form  of  suture. 

Fig   8. — A  suture  ligature. 


or  eight  inches  away  from  the  navel.  Her  hands  need  not  be  safe,  but  the  opera- 
tor's are  prepared  as  for  an  operation. 

"A.  Simple  Ligature.  —  With  blunt-pointed  scissors  snip  all  around 
the  skin  margin,  avoiding  the  place  where  the  vein  shows  near  the  surface  (Figs.  62 
and  63) .  At  this  place  it  is  not  always  easy  to  cut  the  sheath  without  opening  the 
vein.  The  sheath  and  gelatin  are  stripped  backward  with  as  much  jelly  as  possible. 
The  vessels  thus  span  the  gap,  standing  alone.  A  fine  silk  or  catgut  ligature,  around 
all  three  or  about  the  vein  alone,  is  placed.  The  ends  of  the  vessels  are  cut  short, 
and  the  cord  is  off.  The  stump  tends  to  roll  inward.  No  antiseptic  solution  should 
have  been  used  unless  one  has  ground  for  fearing  gonococcus  infection.  No  powder 
is  to  be  used.  A  dry  gauze  pad  under  the  binder  suffices.  Scissors,  ligature  ma- 
terial, and  one  or  two  forceps  are  needed,  besides  the  gauze  for  sponge  or  dressing. 
Fine  silk  cuts  itself  out,  the  end  of  the  tied  vessel  seeming  to  reorganize.  This 
method  is  much  more  sure  to  control  bleeding  than  mass  ligature  of  a  cord. 

"B.  Suture.  —  The  cord  is  drawn  upward  by  the  nurse  as  before.  The 
cuff  of  the  skin  is  caught  between  the  palmar  surfaces  of  the  left  thumb  and  index- 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  99 

finger,  and  one  closure  of  the  scissor-blades  severs  the  cord  through  the  capillary 
ring  (Fig.  63).  A  reflux  of  blood  comes  from  the  cord.  Without  letting  go  with  the 
left  hand,  an  artery  clamp  pulls  the  vessels  up ;  the  needle  is  taken  up  in  the  right 
hand,  and  a  simple  continuous  stitch  is  run  across  and  its  ends  are  tied  together; 
or  a  subcuticular  (Kendal-Frank)  is  put  in  place.  If  it  is  desired  to  ligate  as  well 
as  to  sew  with  the  same  silk,  one  loop  of  the  stitch  sweeps  around  the  arteries  and 
the  other  about  the  vein.  Superficial  bites  may  be  taken  in  order  that  the  little 
stitch  of  fine  silk  will  cut  itself  out. 

"Capillary  oozing,  or  a  few  drops  from  the  vein,  are  arrested  by  a  little  pressure 
from  a  plain  sterile  gauze  dressing  under  a  binder.  Scissors,  a  sharp  cutting  needle 
to  penetrate  rather  tough  skin,  fine  black  silk,  gauze,  and  artery  forceps  are  needed. 
The  timid  may  place  the  stitch  or  stitches  before  cutting  at  all,  as  Dr.  George  R. 
Fowler  suggested  to  the  writer. 

"  Objections  to  Complete  Primary  Amputation.  —  (1) 
Increased  danger  of  contact-infection,  owing  to  operation  on  parts  supplied  with 
lymphatics,  as  compared  with  the  ordinary  ligation  of  vessels  and  jelly  on  parts 
having  no  nutrient  capillaries  or  absorbents. 

"  (2)  Lack  of  drainage  in  case  of  infection. 

"  (3)  Danger  of  concealed  secondary  hemorrhage  (hematoma)  after  the  suturing 
method. 

"  (4)  Inaccessibility  of  vessel-ends  in  case  of  bleeding,  as  compared  with  facile 
placing  of  second  ligature  where  stump  is  long. 

"  (5)  Tharisk  of  striking  an  umbilical  hernia. 

"  (6)  As  this  is  surgery,  it  is  not  yet  adapted  to  the  general  practitioner,  and  to 
the  midwife  only  the  pressure  method  can  be  trusted,  if  that  method  proves  safe. 

"To  admit  most  of  these  objections  is  to  confess  that  we,  as  instructors  and 
surgeons,  fail  in  our  attempt  to  drill  the  student  in  hand  cleaning  and  instrument 
boiling  and  avoidance  of  unclean  contacts,  and  that,  as  to  this  generation  of  general 
practitioners,  we  give  them  up.  Our  method  requires  hands  no  cleaner  than  for  a 
vaginal  examination,  and  far  less  wound  knowledge  than  for  the  repair  of  that 
perineal  injury  which  zigzags  through  fascial  and  muscular  planes,  their  anatomy 
disguised  by  stretching  and  edema. 

"Even  in  the  matter  of  secondary  hemorrhage  not  controllable  by  pressure,  any 
one  can  roll  open  a  superficial  wound,  draw  up  its  center  with  an  artery  forcep,  and 
seize  and  ligate  an  oozing  vessel  end.  A  hernia  at  birth  calls  for  closure  of  the  canal 
by  sutures  in  any  case.  Hernia  is  exceedingly  rare  at  this  time  (Tarnier  and  Budin) , 
though  common  enough  a  month  or  two  later. 

"  After-care.  —  A  small  square  of  plain  gauze  lies  on  the  wound  and  may 
become  adherent  to  it.  Over  this  a  larger  dressing  is  placed,  and  a  moderately 
snug  binder  is  pinned  or  sewed  on.  As  with  any  other  clean  wound,  the  dressing 
must  not  be  changed  except  for  cause.  The  baby  is  not  tubbed  for  a  week  until 
union  is  secure. 

"The  first  washing  immediately  after  the  operation  has  been  just  sufficient  to 
get  rid  of  any  vernix  caseosa  that  is  present,  and  during  the  week  no  general  wash- 
ing is  needed. 

"Flagg  speaks  of  his  case  healing  under  a  scab.  This  is  produced  by  the  der- 
matol.  It  is  better  to  permit  drainage.  Sanious  oozing,  as  from  any  fresh  wound, 
usually  occurs.     In  some  instances,  on  rolling  the  wound  outward  on  the  third  or 


100  THE    UMBILICUS    AND    ITS    DISEASES. 

fifth  day,  the  inverted  skin-cuff  is  found  to  be  moist.  It  may  be  that  there  is  a 
watery  discharge  from  the  gelatin  within  the  ring  of  skin.  Some  of  the  inversion 
of  the  stump  may  be  prevented,  and  a  handsomer  flush  result  secured  by  taking 
off  part  or  all  of  the  skin-cuff.  Dry  primary  union  is  thus  more  certain.  Most 
adult  navels  are  dirt  accumulators — accumulators  not  easy  to  clean.  Deep  in- 
version, with  the  line  of  union  solidly  fixed,  1  to  1.5  cm.  below  the  level  of  the  skin 
of  the  abdomen,  may  be  found  by  the  ninth  day  if  the  whole  skin  projection  is  used 
as  flap." 

I  wrote  Dr.  Dickinson  asking  what  his  experience  had  been  in  the  ten  years  in- 
tervening since  his  paper,  and  received  the  following  answer : 

"Your  query  about  my  immediate  amputation  of  the  cord  did  me  good.  Noth- 
ing ever  fell  as  flat  and  as  hard  as  that  proposition.  The  principles  of  surgery  don't 
apply  to  the  only  operation  done  on  every  living  being,  savage,  civilized,  or  four- 
footed.  I  can  be  satisfied  to  wait,  but  the  method  will  not  be  general  till  every 
practitioner  can  do  a  little  clean  work.  Meanwhile  I  have  gone  straight  on  with  the 
second  procedure.  The  cord  is  lifted  by  nurse  or  assistant.  A  really  sharp  curved 
needle,  armed  with  No.  0  or  No.  1  catgut  or  fine  silk  or  linen,  is  passed  into  the  very 
tough  skin,  beginning  below  the  navel,  just  where  the  skin-cuff  rises  from  the  belly- 
wall.  It  circles  beneath  the  skin,  and  comes  out  above  at  the  base  of  the  skin-cuff. 
The  needle  reenters  close  to  its  first  entrance  and  circles  the  remaining  half,  coming 
out  near  the  original  second  entrance.  It  is  an  over  and  over  stitch  of  a  round 
space  that  sweeps  about  the  circle  as  well,  thus  acting  as  suture  and  encircling  liga- 
ture in  two  bites  and  one  tie.     The  stitch  is  placed  before  the  cord  is  cut. 

"The  cord  is  cut  just  at  the  skin  margin,  under  a  little  traction,  in  order  that 
most  of  the  jelly  may  come  away  in  the  scissors.  Then  an  anatomic  forceps  slips 
the  loop  of  the  middle  part  of  the  stitch  over  the  center  of  the  raw  surface,  and  one 
ties.     It  falls  out  or  is  nipped  out  in  two  or  three  days. 

"The  only  contraindications  are  unclean  contacts  between  exit  of  child's  navel 
and  operation,  umbilical  hernia,  and  a  circulation  badly  started,  so  that  there  is 
back  pressure  in  the  vein. 

"I  have  never  seen  oozing  or  temperature  in  my  own  cases.  The  only  case  I 
know  of  that  did  badly  is  a  baby  whose  navel  was  sutured  by  an  intern  in  a  Brooklyn 
hospital,  that  died  after  some  temperature,  with  a  clean  navel  and  no  autopsy." 

Buckmaster,  in  1906,  suggested  a  treatment  of  the  cord  very  similar  to  that 
carried  out  by  Dickinson,  although  he  was  evidently  unaware  of  the  latter's  work. 

Buckmaster  in  substance  said  that  for  several  years  he  had  been  impressed  with 
the  idea  that  if  the  umbilical  wound  could  be  made  to  heal  by  first  intention,  it 
would  be  of  great  advantage.  He  made  no  claim  to  priority  in  suggesting  a  method 
by  which  this  could  be  done,  and  said  that  he  did  not  know  who  deserved  credit  for 
such  a  suggestion,  since  the  more  reasonable  the  plan,  the  more  likely  it  is  to  occur  to 
a  number  of  men.  He  had  tried  the  new  plan  in  8  cases :  in  6  the  results  were  all 
that  could  be  wished  for.  In  2  cases  of  the  8  there  was  a  slight  trouble  in  the  heal- 
ing of  the  wound,  but  not  enough  to  affect  the  general  result.  In  all  cases  the  wound 
was  closed  in  ten  days,  and  instead  of  a  cicatrix,  there  was  a  slight  linear  scar. 
These  children  had  been  started  in  life  without  an  umbilicus,  and  he  has,  therefore, 
used  the  term  "  anomphalosis  "  as  the  title  of  his  article.     His  operation  is  as  follows : 

"With  a  sharp  pair  of  scissors  free  the  belly-wall,  reflected  on  the  cord  like  a  cuff, 
and  push  it  back.     When  this  has  been  done,  the  cord  may  be  divided.     Sometimes 


UMBILICAL    INFECTIONS    IN    THE    NEW-BORN.  101 

an  artery  may  spurt  a  little,  but  torsion  or  a  thin  catgut  ligature  will  quickly  con- 
trol the  hemorrhage.  It  will  be  noticed  that  in  cutting  through  the  cord  near  the 
wall  how  much  more  fibrous  tissue  is  found  than  one  would  expect. 

"The  condition  now  present  is  a  circular  pit  surrounded  by  a  ridge  of  skin,  the 
top  of  which  is  raw.  By  drawing  two  points  on  opposite  parts  of  the  ridge  from 
each  other,  the  circle  is  changed  to  an  ellipse.  The  sides  of  the  ellipse  are  now  drawn 
together  by  sutures,  preferably  silver  wire,  and  in  from  six  to  ten  clays  the  wound  is 
closed,  practically  by  first  intention. 

"The  condition  is  like  an  amputation  of  an  arm:  in  both  cases  we  have  a  flap 
which  is  made  from  the  skin  and  which  covers  the  stump.  Since  I  first  commenced 
to  discuss  this  procedure  among  my  friends  who  are  interested  in  obstetrics  I  find 
that  many  have  tried  it.  But  while  they  have  no  good  objection  to  the  procedure, 
it  did  not  seem  to  impress  them  favorably.  I  believe  time  will  change  all  this. 
Xo  anesthetic  is  necessary,  because  the  child  suffers  next  to  nothing,  but  the  oper- 
ator should  work  quickly  and  not  where  the  mother  or  non-professional  spectators 
might,  through  their  ignorance,  fancy  the  child  was  maltreated." 

Simple  Surgical  Treatment  of  the  Umbilical  Stump. 
— The  method  recommended  by  Nadory  *  complies  with  the  three  requirements  of 
Ahlfeld,  i.  e.,  that  there  be  positive  prevention  of  an  infection,  protection  against 
secondary  hemorrhages,  and  no  necessity  for  after-treatment.  As  soon  as  the  pul- 
sation of  the  umbilical  cord  ceases  the  cord  is  tied  tightly  with  a  heavy  silk  ligature 
at  the  line  of  demarcation  between  the  skin  and  Wharton's  jelly.  The  cord  is  then 
cut  short.  The  stump  and  umbilical  ring  are  painted  with  tincture  of  iodin.  The 
child  can  be  bathed  daily  if  an  application  of  the  tincture  of  iodin  is  made  after  the 
bath.  The  umbilical  stump  will  fall  off  on  the  second  or  third  day.  The  umbilical 
funnel  heals  rapidly  (J.  Voigt). 


CARE  OF  THE  UMBILICAL  STUMP— A  BACTERIOLOGIC  STUDY. 

After  briefly  considering  the  clinical  aspect  of  the  infections  and  referring  to  the 
recent  literature  on  the  subject,  Adairf  gave  the  results  of  his  bacteriologic  exam- 
inations. "In  order  to  prove  the  presence  or  absence  of  organisms  on  and  around 
the  umbilical  cord  immediately  after  birth,  the  following  procedure  was  adopted: 

"A  platinum  loop  was  used  to  scrape  the  cord  and  surrounding  skin  immediately 
after  birth  and  before  the  cord  was  handled  or  manipulated  in  any  way.  Agar  plate 
cultures  were  made  from  the  material  caught  on  the  platinum  loop.  All  these 
cultures  were  made  under  as  nearly  the  same  conditions  as  possible  in  the  Elliot 
Memorial  Hospital  at  the  University  of  Minnesota.  No  attempt  was  made  to 
isolate  the  anaerobic  organisms. 

"There  were  65  cases  examined  in  all.  In  17  of  these  there  was  no  growth. 
Xon-pathogenic  organisms  were  found  independently  of  any  pathogens  in  33  cases, 
or  over  50  per  cent  of  those  examined.  Pathogenic  organisms  were  found  alone  or 
associated  with  non-pathogens  in  12,  or  19.46  per  cent.  Some  variety  of  staphy- 
lococcus was  found  in  8  instances,  and  some  form  of  the  Bacillus  coli  group  in  4 
cases. 

*  Xadory,  B.:  Einfache  chirurgische  Versorgung  des  Nabelschnurrestes.  Zentralbl.  f.  Gynak., 
1913,  xxxvii,  765.     Surgery,  Gynecology  and  Obstetrics,  November,  1913,  556. 
t  Adair:  Jour.  Amer.  Med.  Assoc,  August  23,  1913,  537. 


102  THE    UMBILICUS    AND    ITS    DISEASES. 

"The  significance  of  this  is  evident.  The  cord  and  its  surroundings  show  the 
presence  of  pathogenic  organisms  in  nearly  one-fifth  of  the  cases  immediately  after 
birth.  This  is  true  where  the  cases  are  conducted  amid  the  aseptic  surroundings  of 
a  delivery  room.  The  percentages  might  easily  be  much  higher  where  less  rigorous 
asepsis  is  carried  out.  This,  of  course,  is  no  argument  for  carelessness  in  the  subse- 
quent handling  of  the  cord,  for  it  may  be  infected  at  any  time. 

"What  are  the  essentials  for  the  growth  of  organisms?  (1)  The  presence  of  the 
germs;  (2)  the  proper  degree  of  temperature;  (3)  a  suitable  culture-medium  and 
environs;  and  (4)  the  presence  of  moisture. 

"It  is  evident  that  it  will  be  very  difficult  .to  eliminate  entirely  the  presence  of 
bacteria,  but  we  can  avoid  contaminating  the  parts  with  germs,  and  we  can  assist 
in  their  removal  by  the  use  of  aseptic  and  antiseptic  measures.  The  body  heat 
furnishes  the  proper  temperature,  and,  of  course,  cannot  be  interfered  with. 

"The  devitalized  tissue  of  the  cord  forms  a  fine  medium  for  the  growth  and 
development  of  the  organisms.  This  can  be  removed  by  ligating  or  clamping  the 
cord  close  to  the  skin  margin.  It  has  been  pretty  well  demonstrated  that  better 
results  are  obtained  by  leaving  as  little  cord  as  possible.  Doubtless  the  methods  of 
amputation  proposed  by  Dickinson,  which  in  his  hands  have  given  almost  ideal 
results,  accomplish  this  most  thoroughly. 

"The  presence  of  moisture  may  be  controlled  by  having  a  small  stump  of  cord 
and  keeping  it  under  conditions  which  favor  rapid  drying.  Various  experiments 
have  been  conducted  along  this  fine,  and  it  has  been  found  that  exposure  to  air  is 
one  of  the  best  means  of  accomplishing  this  end.  Hygroscopic  powders  have  been 
used  with  some  success;  good  results  have  been  obtained  by  the  use  of  astringent 
and  inert  powders.  Equally  good,  or  better,  results  have  been  obtained  without 
any  dusting  powder.  Oily  dressings  have  not  given  as  good  results.  Dry  occlusive 
dressings  have  been  used.  Gauze  seems  to  permit  of  better  and  more  rapid  mum- 
mification than  cotton. 

"In  order  to  fulfil  these  conditions,  the  new-born  babies  have  been  treated  as 
follows  at  the  University  of  Minnesota  Hospital: 

"After  cessation  of  pulsation,  the  cords  were  clamped  near  the  skin  margin,  the 
surrounding  skin  and  cord  cleansed  with  alcohol,  and  the  clamp  removed,  to  be 
replaced  by  a  ligature  in  the  groove  made  by  the  clamp.  The  end  of  the  cord  and 
the  surrounding  skin  were  painted  with  one-half  strength  tincture  of  iodin  in  some 
cases,  and  in  others  left  untreated.  A  sterile  gauze  dressing  was  then  tied  over 
the  end  of  the  cord.  The  babies  were  oiled  for  three  days,  then  washed,  but  no 
tub-baths  were  given  until  the  navel  was  healed.  Each  day  the  stump  and  sur- 
rounding skin  was  washed  with  alcohol  and  the  dressing  changed  when  necessary. 

"A  study  of  the  clinical  courses  of  these  cases  subsequent  to  delivery  may  be  of 
interest  and  profit. 

"First  in  order  is  a  consideration  of  those  cases  from  which  cultures  were  taken. 
In  all  there  were  65  cases;  one  of  these  was  a  still-birth;  there  were  3  unsatisfactory 
cultures,  which  leaves  61  for  study. 

"There  were  17  cases  which  showed  no  growth;  of  these,  4,  or  23.5  per  cent, 
showed  a  febrile  reaction  of  over  100°  F.  There  was  one  case  with  jaundice,  and 
the  average  maximum  weight  loss  was  209  gm. 

"Of  the  32  cases  from  which  non-pathogenic  organisms  were  recovered,  there 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  103 

were  8,  or  25  per  cent,  with  febrile  reaction;  3  infants  were  jaundiced,  and  the 
average  maximum  loss  of  weight  was  188  gm. 

"There  was  a  temperature  rise  in  3,  or  25  per  cent,  of  the  12  cases  in  which 
pathogenic  organisms  were  found;  one  was  jaundiced,  and  the  average  maximum 
weight  loss  was  202  gm. 

''The  figures  are  so  close  for  the  different  groups  that  the  only  conclusion  one 
could  draw  would  be  that,  so  far  as  this  series  is  concerned,  it  made  little  difference 
whether  or  not  the  organisms  were  present  at  birth. 

"  There  was  no  definite  evidence  of  any  serious  infection  of  the  navel.  Two  were 
somewhat  reddened  without  any  febrile  reaction,  jaundice,  or  marked  loss  of  weight. 
There  were  two  with  some  foul  odor,  one  had  a  febrile  reaction  of  102°  F.  and  a 
weight  loss  of  340  gm.  The  other  had  no  reaction.  Neither  had  any  jaundice. 
A  number  of  others  did  not  heal  so  rapidly  as  usual,  but  showed  no  signs  of  infection. 
None  of  these  babies  died,  and  all  left  the  hospital  in  good  condition. 

"Fifty-eight  infants  were  treated,  as  outlined  above,  with  alcohol  and  dry  dress- 
ings. Of  these,  14,  or  24.13  per  cent,  had  a  rise  in  temperature  to  100°  F.  or  over; 
8,  or  13.08  per  cent,  were  jaundiced,  and  of  these  4  had  fever  and  there  was  an 
average  maximum  loss  of  weight  of  246.2  gm.  The  average  loss  of  weight  in  the 
febrile  cases  was  314  gm.  Five,  or  8.6  per  cent,  had  slight  local  evidence  of  navel 
infection,  but  none  of  them  had  a  temperature  rise  to  100°  F.  The  cord  came  off 
in  five  and  one-half  days  on  an  average. 

"In  the  second  series  of  cases  tincture  of  iodin  was  used  to  paint  the  cord  and 
surrounding  skin.     Otherwise  the  treatment  was  the  same  as  in  the  preceding  series. 

"There  were  186  babies  treated  in  this  way.  The  temperature  rose  to  100°  F. 
or  above  in  42,  or  22.58  per  cent,  of  these;  15,  or  8  per  cent,  were  jaundiced,  of 
which  5  had  a  febrile  reaction.  The  average  loss  of  weight  was  228.05  gm.  In  the 
cases  with  fever,  this  loss  amounted  to  285.19  gm.  Ten,  or  5.37  per  cent,  had 
slight  local  evidence  of  infection  of  the  navel,  only  3  of  which  had  any  fever.  The 
cord  came  off  in  seven  and  one-half  days  on  an  average.  None  of  the  babies  in 
either  series  had  any  evidence  of  serious  or  fatal  infection  originating  at  the  navel. 
How  many  of  these  febrile  cases  were  caused  by  absorption  of  some  toxic  substance 
or  the  entrance  of  organisms  through  the  umbilicus  it  is  not  possible  to  state. 
Many  conclusions  cannot  be  drawn  from  this  rather  small  amount  of  material. 

"It  is  evident  that  some  facts  can  be  stated. 

"1.  The  cord  is  contaminated  with  pathogenic  or  non-pathogenic  organisms 
at  or  immediately  after  birth  in  a  large  percentage  of  cases. 

"2.  It  is  possible  quite  effectively  to  combat  serious  umbilical  infections  by 
comparatively  simple  methods,  as  shown  by  this  report  of  over  200  cases  with  no 
mortality  from  this  cause. 

"3.  There  seems  to  be  little  choice  between  the  two  methods  used  in  these  cases. 

"4.  Jaundice  in  the  new-born  child  is  frequently  associated  with  fever.  It 
would  not  be  illogical  to  suspect  that  this  might  originate  by  some  agent  introduced 
through  the  umbilical  vein  or  lymphatics. 

"5.  Febrile  reactions  are  common  in  the  new-born  infant,  and  are  associated 
with  other  disturbances,  such  as  a  high  primary  weight  loss  and  jaundice.  They  are 
due,  no  doubt,  to  many  causes,  but  we,  as  obstetricians,  should  see  that  those  due 
to  infections  entering;  at  the  umbilicus  are  reduced  to  an  irreducible  minimum." 


104  THE    UMBILICUS    AND    ITS    DISEASES. 

PERSISTENT  VITALITY  OF  THE  UMBILICAL  CORD. 

Occasionally  the  cord  does  not  come  away  promptly.  This  is  prone  to  occur  if 
the  cord  has  been  tied  at  a  point  too  far  remote  from  the  umbilicus.  This  phenom- 
enon was  very  well  shown  in  a  case  reported  by  Williams  in  1880,  and  in  cases  de- 
scribed by  Dorland  in  1897. 

Williams'  patient  was  a  child  three  weeks  old.  A  fleshy  outgrowth  an  inch  long 
projected  from  the  umbilicus.  It  was  rigid,  had  a  raw,  granulating  appearance, 
and  bled  on  the  slightest  touch.  It  was  sensitive  and  had  a  little  central  opening 
on  its  free  extremity.  The  dressings  were  frequently  changed  on  account  of  a 
watery  oozing.  The  central  depression  did  not  lead  into  a  canal.  A  strong  silk 
ligature  was  applied  to  the  base  of  the  projection.  The  next  day  nothing  was  visible 
but  a  small  shred  of  dead  tissue,  which  was  nipped  off  after  three  days.  The  child 
made  a  perfect  recovery. 

Dorland  said  that  within  a  period  of  ten  months  he  had  two  cases  in  which  the 
cord  did  not  come  away  readily.  He  mentioned  a  case  in  which  the  cord  had  not 
come  away  at  the  end  of  the  eighth  week,  and  was  then  amputated  close  to  the 
umbilicus.  In  this  case  the  tissue  was  almost  cartilaginous.  In  Dorland's  cases 
the  cord  did  not  separate  until  the  ninth  and  sixteenth  days  respectively.  In 
Case  1  there  was  fissuring  of  the  cord  close  to  the  abdominal  wall.  The  child,  on 
the  eighth  day,  developed  convulsions,  a  persistent  high  temperature,  and  inflam- 
mation of  the  umbilicus.     It  died  on  the  following  day. 

In  the  second  case  the  cord  was  amputated  on  the  sixteenth  day.  There  was  a 
slight  oozing  for  two  days,  but  the  child  recovered. 

LITERATURE  CONSULTED  IN  THE  PREPARATION  OF  UMBILICAL  INFECTIONS  IN 

THE  NEW-BORN. 

No  attempt  has  been  made  to  cover  the  subject. 

Adair,  Fred.  L.:  Care  of  the  Umbilical  Stump.  A  Bacteriologic  Study.  Section  on  Obst., 
Gyn.,  and  Abdom.  Surg,  of  the  Amer.  Med.  Assoc,  at  the  Sixty-fourth  Annual  Session  held 
at  Minneapolis  June,  1913.     Jour.  Amer.  Med.  Assoc,  August  23,  1913,  537. 

Bednar,  A. :  Die  Krankheiten  der  Neugeborenen  und  Sauglinge.     Wien,  1852,  168. 

Bergeron,  H. :  Une  epidemie  de  gangrene  de  l'ombilic.     These  de  Paris,  1866,  No.  59. 

Buckmaster,  A.  H. :  Anomphalosis.     Trans.  Amer.  Gyn.  Soc,  1906,  xxxi,  306. 

Cohn,  M.:  Zur  Lehre  von  den  septico-pysemischen  Nabelinfectionen  der  Neugeborenen  und  ihrer 
Prophylaxe.     Therap.  Monatsschr.,  1896,  x,  130;  192. 

Cumston,  C.  G. :  Infection  of  the  Umbilicus  in  the  Newly  Born.  New  York  and  Phila.  Med. 
Journal,  1905,  lxxxi,  81. 

Dickinson,  R.  L. :  Is  a  Sloughing  Process  at  the  Child's  Navel  Consistent  with  Asepsis  in  Child- 
bed? An  Introduction  to  the  Study  of  Complete  Primary  Amputation.  Amer.  Jour.  Obst., 
1899,  xl,  14. 

Dorland,  W.  A.  N. :  Persistence  of  the  Umbilical  Cord.     Phila.  Polyclinic,  1897,  vi,  254. 

Gremillon:  Anomalies  et  des  complications  de  la  cicatrisation  de  l'ombilic.  These  de  Paris, 
1895,  No.  453. 

Hinsdale,  G. :  Purulent  Encephalitis  and  Cerebral  Abscess  in  the  New-born  Due  to  Infection 
Through  the  Umbilicus.    Amer.  Jour.  Med.  Sci.,  N.  S.,  1899,  cxviii,  280. 

Lambert,  S.  W. :  Umbilical  Sepsis  in  the  New-born  Occurring  at  the  Nursery  and  Child's  Hospital, 
New  York,  during  1896.     Med.  News,  Phila.,  1897,  lxx,  557. 

Lorain,  Paul:  De  la  fievre  puerperale  chez  la  femme,  le  foetus,  et  le  nouveau-ne.  These  de  Paris, 
1855,  No.  161. 

Maygrier,  M.  C:  Infection  generalisee  d'origine  ombilicale  probable  chez  un  nouveau-nc. 
Bull,  de  la  Soc.  d'obst.  de  Paris,  1901,  iv,  146. 


UMBILICAL   INFECTIONS    IN    THE    NEW-BORN.  105 

Meyer:    Puerperal-Infection  eines   Neugeborenen.     St.  Petersburger  med.  Wochenschr.,  1891, 

xvi,  423. 
Meynet,  C.  H.  P.:   Epidemie  d'erysipele  et  d'ulceration  de  l'ombilic.     These  de  Paris,  1857,  xi, 

No.  156. 
Nadory,   B.:    Einfache  chirurgische  Versorgung  des  Nabelschnurrestes.      Zentralbl.  f.  Gynak., 

1913,  xxxvii,  765;   Surgery,  Gynecology  and  Obstetrics,  November,  1913,  556. 
Nicaise:  Ombilic.     Dictionnaire  encycloped.  des  sci.  med.  Paris,  2.  ser.,  xv  (1881),  140. 
Pinkerton,  J.:    A  Case  of  Omphalitis,  Umbilical,  Closure  of  Ulcer  by  a  Plastic  Operation;   Re- 
covery with  a  Firm  Cicatrix.     The  Lancet,  1900,  i,  1656. 
Pollak:  Nabelbrand,   Darmfistel,  Tod.    Jahrb.  f.  Kinderheilk.  u.  phys.  Erziehung,  1869-70,  iii, 

227. 
Porak:  Infection  generalisee  chez  un  nouveau-ne  consecutive  a  une  phlebite  ombilicale  sup- 
puree.     Bull,  de  la  Soc.  d'obst.  de  Paris,  1901,  iv,  142. 
Porak,  C,  et  Durante,  G. :    Infections  ombilicales  du  nouveau-ne.     Arch,  de  med.  des  enfants, 

1905,  viii,  449. 
Ribbert:    Abscesse  des  Gehirns,  veranlasst  durch  Embolien  des  Oidium  albicans.     Berl.  klin. 

Wochenschr.,  1879,  xvi,  617. 
Runge:    Die  Krankheiten  der  ersten  Lebenstage.     Stuttgart,  1893,  56. 
Salge,  B. :  Ein  Beitrag  zur  septischen  Infektion  des  Nabels  des  Neugeborenen.    Charite-Annalen, 

1904,  xxviii,  263. 
Tarnier  et  Budin:  Traite  de  l'art  des  accouchements,  1901,  iv,  728. 
Trousseau,  M.:   De  l'erysipele  chez  les  enfants  a  la  mamelle.     Jour,  de  med.  et  de  chir.,  1844, 

ii,  1. 
Wassermann,  M.:    Ueber  eine  Epidemie-artig  aufgetretene  septische  Nabel-Infection  Neugebo- 

rener:   ein  Beweis  fiir  die  pathogenetische  Wirksamkeit  des  Bacillus  pyocyaneus  beim  Men- 

schen.     Virchows  Arch.,  1901,  clxv,  342. 
Williams,  C.  R. :  Persistent  Vitality  of  the  Umbilical  Cord.    The  Lancet,  1880,  i,  701. 
Yot,  E. :  De  l'erysipele  innammatoire  ou  non-puerperal  des  enfants  nouveau-nes.     These  de  Paris, 

1873,  No.  240. 


CHAPTER  IV. 
UMBILICAL  HEMORRHAGE. 

General  consideration. 

Causes  of  umbilical  hemorrhage. 

Treatment. 

Instances  of  umbilical  hemorrhage  in  the  new-born. 

Umbilical  hemorrhage  in  patients  after  infancy. 

Hematoma  of  the  abdominal  wall  near  the  umbilicus. 

To  discuss  thoroughly  the  enormous  amount  of  literature  on  this  subject  would 
occupy  many  pages.  I  shall  merely  give  the  salient  facts,  and  report  enough  cases 
to  give  a  clear  idea  of  the  fatalities  resulting  from  umbilical  hemorrhage. 

The  manner  in  which  umbilical  hemorrhage  is  checked,  even  though  no  ligature 
be  applied,  is  probably  explained  by  Fig.  64.  The  inner  longitudinal  muscular 
coat  contracts  and  thickens,  thus  tending  to  obliterate  the  lumen  of  the  vessel. 
We  know  that  in  many  animals,  in  fact  in  practically  all,  the  cord  is  bitten  or  torn 
off,  no  ligature  being  applied. 

Craig  (1894),  in  his  article  on  Umbilical  Hemorrhage,  quoted  J.  Foster  Jenkins, 
who  in  1858  published  a  monograph  giving  the  histories  of  178  cases,  and  mentions 
Grandidier,  who  had  collected  202  cases.  In  about  one-third  of  the  cases  the  hem- 
orrhage occurred  in  female  children;  in  two-thirds,  in  male  children. 

Craig  states  that  the  time  of  greatest  danger  is  when  the  cord  comes  away — 
from  the  fifth  to  the  fifteenth  day.  As  the  chief  causes  of  hemorrhage  he  mentions 
a  faulty  condition  of  the  blood,  pathologic  conditions  of  the  vessel-walls,  hemophilia. 
He  adds  that  a  condition  of  ill  health  or  anemia  in  the  mother,  due  to  any  cause, 
produces,  to  a  certain  degree,  a  like  condition  in  her  offspring. 

Without  any  premonition  of  the  impending  danger,  the  clothes  are  found 
soaked  with  blood.  In  41  out  of  175  of  Craig's  cases  the  hemorrhage  was 
preceded  by  jaundice.  The  most  dangerous  hemorrhages  occurred  at  night. 
About  90  per  cent  of  the  children  die.  Where  jaundice  and  hemophilia  are  pres- 
ent, the  condition  is  most  hopeless  (Craig). 

Cumston,  in  1905,  writing  on  infections  of  the  umbilicus  in  the  new-born,  says 
that  certain  accidents,  such  as  late  umbilical  hemorrhages  arising  from  the  changes 
in  the  vessels,  are  often  due  to  hemophilia,  hereditary  syphilis,  and  a  kind  of  heredi- 
tary family  predisposition.     These  conditions  have  been  observed  by  Boissard. 

Demelin  (quoted  by  Cumston)  divides  umbilical  hemorrhages  occurring  secon- 
darily or  spontaneously  into  the  three  following  groups:  (1)  Hemorrhage  due  to  an 
arteritis  occurring  about  the  time  the  cord  falls  off.  (2)  Hemorrhage  occurring  in 
acute  degeneration  of  the  infant,  "with  icterus  of  infective  origin.  (3)  Hemorrhage 
in  cases  of  septicemia  of  the  newly  born,  which  is  produced  by  the  same  mechan- 
ism as  holds  in  cases  of  congenital  syphilis  following  umbilical  inflammation. 

Gallant,  in  1907,  gave  a  good  resume  of  the  subject  of  umbilical  hemorrhage, 
and  added  an  excellent  table  of  the  reported  cases. 

106 


UMBILICAL    HEMORRHAGE. 


107 


Runge  (op.  cit.,  p.  197)  says  that  cases  of  umbilical  hemorrhage  in  which,  on 
anatomic  examination,  no  syphilis  was  present,  have  been  reported  by  Wachsmuth, 
Weiss,  Hryntshak,  Fischel,  and  others. 

According  to  Mracek,  the  hemorrhage  is  caused  by  disease  of  the  small  and 
large  veins.  In  the  walls,  especially  of  the  veins,  is  found  a  thickening  due  to  mul- 
tiplication of  the  nuclei.  He  found  the  lumen  narrow,  and  in  several  cases  com- 
pletely closed. 

Runge  (p.  198)  asserts  that  septic  diseases  of  the  new-born  have  been  proved  to 
be  the  cause  of  idiopathic  bleeding  by  the  observations  of  Weber,  Ritter,  and  Ep- 
stein. Capillary  hemorrhages  are 
relatively  common  in  septic  cases, 
but  in  addition  severe  bleeding 
from  various  organs  has  been  ob- 
served in  septic  diseases  of  the 
new-born,  especially  in  foundling 
hospitals.  Epstein  found  bleed- 
ing 24  times  in  51  children  suffer- 
ing from  a  well-developed  acute 
septicemia.  Runge  notes  that, 
in  cases  in  which  bleeding  took 
place,  there  was  often  gangrene  of 
various  parts  of  the  surface  of  the 
body.  In  cases  of  general  septi- 
cemia there  is  a  tendency  toward 
hemorrhage;  various  organs  may 
be  affected,  and  as  a  result  we 
may  have  bleeding  from  the  um- 
bilicus. 

The  hemorrhage  is  sometimes 
noted  a  few  hours  after  birth.  In 
each  of  the  three  cases  recorded 
by  Kommerell  the  bleeding  oc- 
curred a  few  hours  after  birth, 
but  all  the  infants  recovered. 

In  his  first  case  the  mother 
reported  that  her  first  child 
had  had  severe  umbilical  hemor- 
rhages, and  she  had  asked  the 

midwife  to  be  particularly  careful.  The  midwife  accordingly  had  tied  the  cord  twice 
with  firmness  and  extra  care,  and,  when  she  left,  it  was  in  good  condition.  Later, 
however,  a  severe  hemorrhage  occurred.  The  bleeding  ceased  spontaneously  and 
the  child  recovered. 

In  Kommerell's  second  case  the  midwife  had  tied  the  cord  a  second  time  and  the 
father  had  seen  that  it  was  properly  done.  During  the  night  the  child  was  restless; 
in  the  morning  it  was  very  pale,  and  there  had  been  severe  bleeding  from  the  cord. 
The  hemorrhage  stopped  spontaneously  and  the  child  recovered. 

The  fact  that  these  bleedings  occurred  several  hours  after  birth,  according  to 
Kommerell,  is  easy  of  explanation.     After  being  cut  the  blood-vessels  contract, 


wV 


II,  , 

Coturacte  ct>; 
Itmgitdfdinal 
|  m  use  lei-  closing 
til iH  ,'iLuThen ,■:'■:. 

m 


Fig.  64. — Natuhe's  Method  op  Checking  Bleeding  fbom  the 
Umbilical  Arteries. 
On  the  left  we  have  transverse  and  longitudinal  sections  of 
an  artery  showing  the  intima,  the  thick  longitudinal  muscular 
coat,  and  the  outer  circular  coat.  When  the  vessel  is  cut  across 
in  the  living,  the  longitudinal  muscle  probably  contracts,  as  indi- 
cated by  the  arrows,  forming  an  effectual  barrier  to  the  further 
escape  of  blood.  Were  it  not  for  some  such  mechanism  as  this, 
many  animals  would  perish,  since  in  their  case  the  cord  is  left  to 
take  care  of  itself. 


108  THE    UMBILICUS    AND    ITS    DISEASES. 

while  at  the  same  time  the  blood-pressure  is  diminishing.  The  intra-abdominal 
portion  of  the  umbilical  artery  continues  to  pulsate  after  pulsation  has  ceased  in  the 
extra-abdominal  portion.  If,  now,  the  soft  mass  within  the  umbilical  pedicle  loses 
in  energy,  while  in  the  intra-abdominal  part  the  umbilical  vessels  are  still  filled, 
hemorrhage  can  readily  occur. 

Kommerell  reports  another  case  in  which,  several  hours  after  the  midwife  had 
tied  the  cord,  fatal  hemorrhage  occurred.  The  midwife  was  sentenced  to  eight  days 
in  jail.  Kommerell  then  goes  on  to  discuss  the  responsibility  in  such  cases.  In 
Sibert's  case  the  infant  died  of  umbilical  hemorrhage  thirty  hours  after  birth.  The 
cord  was  three-quarters  of  an  inch  in  diameter.  On  account  of  "unusual  excite- 
ment" in  the  cord,  tying  was  delayed.  Sibert  saw  the  child  twenty  hours  after 
birth.  It  was  pale  and  was  bleeding  from  the  umbilicus.  The  ligature  was  not 
found  when  the  cord  was  examined.  A  second  was  applied.  After  a  time  the 
bleeding  recurred.  The  mother's  health  during  gestation  had  been  bad.  There 
was  no  history  of  a  hemorrhagic  diathesis. 

The  hemorrhage  may  occur  two  or  three  days  after  the  birth  of  the  child,  or  an 
interval  of  several  weeks  may  elapse  before  bleeding  is  noted.  In  Craig's  case,  for 
example,  oozing  from  the  umbilicus  was  noted  on  the  second  day.  There  may 
be  hemorrhages  at  irregular  intervals,  extending  over  a  period  of  from  a  few 
hours  to  two  or  three  days,  or,  as  in  Garcin's  case,  the  hemorrhage  may  be  so  severe 
that  the  child  dies  in  a  few  minutes  after  the  bleeding  has  been  detected. 

In  some  cases  the  bleeding  is  intermittent,  in  others,  constant.  Stuart's  de- 
scription of  the  bleeding  in  his  case  is  graphic:  "It  reminded  one  of  the  water  bub- 
bling through  sand  at  the  bottom  of  a  spring;  only  the  oozing  and  welling  up  from 
the  stump  of  the  cord  were  very  deliberate  and  slow." 


CAUSES  OF  UMBILICAL  HEMORRHAGE. 

The  most  frequent  causes  of  umbilical  hemorrhage  appear  to  be  heredity,  in- 
fection, and  syphilis. 

Heredity.- — ■  Tajdor,  in  1893,  reported  three  cases  occurring  in  one  family; 
the  mother's  first  cousin  had  lost  two  children  from  umbilical  hemorrhage. 

Infection.  —  Umbilical  infection,  with  its  subsequent  general  infection 
and  jaundice,  evidently  plays  a  very  important  role  in  the  development  of  hemor- 
rhage from  the  umbilicus.  In  Chapter  III  it  has  been  noted  that,  before  the  days 
of  asepsis,  when  outbreaks  of  puerperal  sepsis  developed  and  many  mothers  suc- 
cumbed, there  was  a  correspondingly  large  percentage  of  umbilical  infections  in  the 
new-born.  Fortunately,  this  is  in  large  measure  a  thing  of  the  past.  Thus  Gar- 
cin,  in  1903,  when  reporting  a  fatal  secondary  hemorrhage  from  the  umbilicus  eight 
days  after  birth,  could  say:  "I  have  never  had  one  like  it,  although  I  have  officiated 
or  assisted  in  upward  of  a  thousand  obstetrical  engagements." 

Syphilis.  —  Runge  says  that  not  only  Grandidier,  but  also  other  authors, 
have  noted  syphilis  in  the  parents  of  children  that  have  developed  umbilical  bleed- 
ing. Several  writers  have  described  in  detail  the  syphilitic  changes  that  were 
present  in  the  children  during  life  and  after  death,  and  are  inclined  to  regard  this 
disease  as  the  etiologic  factor.     Behrend  described  a  "syphilis  hemorrhagica." 

Runge  says  that  this  form  of  syphilis  only  rarely  affects  children.  When  the 
disease  is  noted  at  birth,  it  is  most  frequently  encountered  in  premature  children, 


UMBILICAL   HEMORRHAGE.  109 

who,  if  not  born  dead,  die  almost  immediately  or  live  only  a  few  hours,  rarely  a  day. 
In  these  cases,  in  addition  to  the  marked  changes,  which  are  usually  those  found  in 
syphilis,  can  be  noted  numerous  hemorrhages  under  the  skin  and  in  the  internal 
organs.  Sometimes  there  are  hemorrhages  into  the  stomach  and  intestine,  into  the 
peritoneal  cavity  and  the  meninges. 

When  such  children  live  for  a  longer  period,  there  occur  new  hemorrhages  in  the 
skin  or  in  the  various  organs.  Runge  cites  the  case  of  a  child  showing  marked  syph- 
ilitic changes,  in  which  hemorrhage  occurred  from  the  edges  of  the  anus  and  from 
the  tip  of  the  tongue,  and  finally,  on  the  eighth  day,  from  the  umbilicus.  The  blood 
came  out  of  the  skin,  just  as  drops  of  sweat  would  do,  and  on  the  ninth  day  marked 
icterus  developed  and  the  child  died.  At  autopsy  extensive  syphilitic  changes  were 
found  in  the  internal  organs. 

TREATMENT. 

Astringents,  such  as  silver  nitrate,  tannic  acid,  and  iron  persulphate,  have  been 
used  with  little  or  no  effect.     Adrenalin  has  proved  of  little  value. 

Attempts  have  been  made  to  check  bleeding  by  encircling  the  umbilicus  with  a 
catgut  or  silk  ligature,  or  by  transfixing  it  with  two  straight  needles  placed  at  right 
angles,  and  tying  a  ligature  beneath  them.  In  this  way  temporary  cessation  of  the 
bleeding  has  occasionally  been  effected,  but  it  soon  recurs.  Our  hope  for  the  future 
seems  to  lie,  in  large  measure  at  least,  in  bringing  about  a  coagulation  of  the  blood. 
The  condition  being,  in  some  cases  at  least,  analogous  to  melsena  neonatorum,  a 
practical  line  of  treatment  should  be  sought  for  along  the  same  lines. 

The  following  case  recorded  by  Reichard  is  of  interest,  although  the  bleeding 
was  not  from  the  umbilicus,  but  from  the  bowel.  It  will  be  noted  that  a  child  of 
this  mother  had  died  of  hemorrhage  on  the  fourth  day. 

Spontaneous  Hemorrhage  of  the  New-born,  with 
Recovery.  —  V.  M.  Reichard  *  reported  the  following  case: 

"Spontaneous  hemorrhage  of  the  new-born  is  so  obscure  and  so  fatal  a  disease 
that  any  experience  pointing  the  way  out  is  worth  recording.  All  treatment  de- 
tailed in  the  literature  of  the  subject  is  so  difficult  a  technic  as  to  require  either 
special  skill  or  special  apparatus  or  both.  In  view  of  these  facts  the  following  case 
is  worthy  of  report: 

"Mrs.  R.,  aged  forty-two,  white,  was  delivered  rapidly  and  easily  of  her  ninth 
child  at  4  p.  m.  August  26,  1912.  She  was  not  in  labor  more  than  thirty  minutes, 
and  the  baby  was  born  fully  half  an  hour  before  the  attendant's  arrival.  The  child, 
a  girl,  weighed  nine  and  one-half  pounds  and  appeared  perfectly  well  and  normal. 
Of  the  eight  children  previously  born,  two  had  died,  one,  the  first-born,  of  some 
bowel  complication  at  four  months;  and  one,  the  fourth,  of  hemorrhage  on  the 
fourth  day.  The  ninth  child  was  well  for  thirty-six  hours,  when  the  nurse  found 
her  listless  and  flaccid.  On  examination  it  was  discovered  that  a  large  quantity  of 
blood  had  been  passed  by  bowel.  Some  of  the  blood  was  red,  but  a  much  larger 
part  was  dark  and  tarry-looking.  I  saw  her  at  9  a.  m.,  August  28th.  The  child 
was  then  of  a  deep  lemon  color  and  in  profound  shock.  She  had  vomited  some  blood. 
During  the  day  she  had  half  a  dozen  bloody  stools,  and  at  9  p.  m.  the  pulse  was  rapid 
and  weak.  She  had  been  very  languid  and  relaxed  all  the  day,  though  she  had 
taken  the  breast  at  three-hour  intervals.     At  9  p.  m.  she  was  given  about  15  c.c.  of 

*  Reichard,  V.  M.:  Jour.  Amer.  Med.  Assoc,  October  26,  1912,  1539. 


110  THE    UMBILICUS    AND    ITS    DISEASES. 

normal  horse  serum  subcutaneously.  August  29th  and  30th  small  amounts  of 
blood  were  passed,  but  each  time  the  amount  was  less,  running  possibly  from  half 
an  ounce  down  to  a  teaspoonful.  At  7  p.  m.  on  the  thirtieth  the  child  was  given 
20  c.c.  of  normal  horse  serum,  and  from  that  time  on  there  has  been  no  blood.  Both 
injections  were  made  into  the  buttocks,  one  on  each  side.  On  September  1st  the 
stools  were  the  usual  yellow  color  of  a  nursing  infant,  and  have  continued  so  ever 
since.  On  September  16th,  when  last  seen,  she  was  a  splendid  specimen  of  baby, 
skin  clear  and  healthy,  and  nursing  well,  bowels  regular,  stools  natural,  and  every 
evidence  of  perfect  health. 

"Twenty  cubic  centimeters  is  a  fairly  large  subcutaneous  dose  for  an  infant, 
and  in  this  case  put  the  skin  on  the  stretch  decidedly.  This  tension  subsided  rap- 
idly, and  in  an  hour's  time  the  tumor  had  disappeared." 

In  .Reichard's  case  the  employment  of  horse  serum  gave  good  results.  Serum 
in  another  form  was  employed  by  Chartier  in  a  case  of  umbilical  hemorrhage,  with 
recovery  of  the  child. 

It  is  also  possible  that  the  newer  and  simpler  methods  of  transfusion  may  yield 
good  results.  These  children  are,  as  a  rule,  too  far  gone  to  permit  of  the  linking-up 
of  a  vessel  with  that  of  a  donor. 


INSTANCES  OF  UMBILICAL  HEMORRHAGE  IN  THE  NEW-BORN. 

Umbilical  Hemorrhage  in  the  New-born.  * — Hemorrhage 
occurred  two  days  after  the  cord  came  away.  During  the  first  three  days  the 
weight  of  the  child  diminished  from  2910  to  2480  gm.  There  were  also  vomiting 
and  diarrhea.  On  the  seventh  day  there  was  an  umbilical  hemorrhage  and  the 
child  became  blanched.  The  umbilicus  was  cauterized  with  nitrate  of  silver.  The 
same  evening  another  hemorrhage  followed,  and  several  drops  of  1 :  1000  adrenalin 
were  applied.  The  next  morning  free  hemorrhage  still  persisted.  The  child  was 
absolutely  colorless,  the  pulse  hardly  perceptible.  Thirty  cubic  centimeters  of 
the  serum  were  injected,  and  two  hours  later  20  c.c.  of  serum  gelatin.  On  the  next 
day  another  injection  of  20  c.c.  of  serum  gelatin  was  given.  The  child  made  a  good 
recovery. 

Chartier  employed  a  sterilized  solution  of  25  gm.  of  gelatin  in  1000  gm.  of 
Hayem's  serum. 

Umbilical  Hemorrhage.  —  C.  F.  Craig  f  reports  a  fatal  case :  "  On 
the  second  day  blood  oozed  from  the  umbilicus  where  the  cord  was  attached. 
Compresses  were  applied,  and  the  bleeding  ceased.  On  the  third  morning  the 
umbilicus  appeared  to  be  in  good  condition,  but  the  child  had  vomited  blood 
several  times.  On  the  following  morning  there  had  been  no  more  vomiting,  but 
the  child  was  jaundiced.  A  few  hours  later  there  was  more  bleeding  from  the 
umbilicus  and  the  child  died  in  the  course  of  a  few  minutes." 

Hemorrhage  from  Umbilicus.  —  Fry  J  reports  the  case  of  a  colored 
child  weighing  seven  pounds  and  four  ounces.  On  the  eighth  day  the  cord  came 
away.     On  the  twelfth  there  was  bleeding  from  the  umbilicus.     Compresses  and 

*  Chartier:  Omphalorragie  grave,  traitement  par  le  serum  gelatine,  guerison.  Arch,  de  m6d. 
des  enfants,  1905,  viii,  477. 

t  Craig,  C.  P. :   The  Medical  News,  1894,  lxv,  569. 

J  Fry,  Henry:  Omphalorrhagia  Neonatorum.     Amer.  Jour.  Obst.,  1907,  lv,  856. 


UMBILICAL   HEMORRHAGE.  Ill 

an  abdominal  binder  were  applied.  On  the  following  day  a  solution  of  1:10,000 
of  adrenalin  chlorid  was  used,  and  forty-eight  hours  later  a  purse-string  of  catgut 
was  tried.  The  bleeding  still  continuing,  two  hours  later  two  needles  were  passed 
through  the  umbilicus  at  right  angles,  the  tissues  were  constricted  with  a  silk  liga- 
ture, and  five  grains  of  calcium  lactate  were  given  every  four  hours.  A  temporary 
cessation  of  the  hemorrhage  ensued.  Styptic  collodion  was  tried,  and  a  compress  of 
10  per  cent  gelatin  solution,  changed  every  two  hours.  A  dram  of  gelatin  solution 
in  two  drams  of  normal  salt  solution  was  injected  under  the  skin.  The  blood  on  the 
second  day  showed:  Red  corpuscles,  3,500,000;  white  corpuscles,  9000;  hemo- 
globin, 70  per  cent.     The  hahy  died  four  days  after  the  onset  of  the  bleeding. 

Fatal  Secondary  Hemorrhage  From  the  Umbilicus 
Eight  Days  After  Birth.  —  In  Garcin's*  case  the  hemorrhage  from  the 
umbilicus  began  on  the  eighth  day  after  birth.  The  labor,  which  was  uncompli- 
cated, occurred  on  October  23,  1902,  and  the  cord  came  away  in  a  normal  manner. 
On  October  31,  the  child  was  bleeding  to  death  from  the  umbilicus.  The  father 
discovered  blood  on  the  bed  when  going  to  work.  On  the  doctor's  arrival  the  child 
was  just  alive.  The  hemorrhage  was  promptly  controlled  by  compresses  of  sterile 
gauze  saturated  with  suprarenal  extract.     The  child,  however,  died  in  a  few  minutes. 

A  Case  of  Fatal  Umbilical  Hemorrhage.!  —  The  infant 
died  of  umbilical  hemorrhage  thirty  hours  after  birth.  The  cord  was  three-quarters 
of  an  inch  in  diameter.  On  account  of  "unusual  excitement"  in  the  cord,  tying 
was  delayed.  Sibert  saw  the  child  twenty  hours  after  birth.  It  was  pale  and  was 
bleeding  from  the  umbilicus.  The  ligature  was  not  found  when  the  cord  was  ex- 
amined; a  second  was  applied.  After  some  time  the  bleeding  recurred  and  the 
child  died.  The  mother's  health  during  gestation  had  been  bad.  There  was  no 
history  of  a  hemorrhagic  diathesis. 

Three  Cases  of  Umbilical  Hemorrhage  Occurring  in 
the  Same  Family.  J  —  Case  1  .  —  A  female  infant,  thirteen  days  old, 
seen  on  September  29th.  She  was  the  eighth  child  of  a  healthy  family.  The  moth- 
er's first  cousin  had  lost  two  children  from  umbilical  hemorrhage.  The  child  was 
a  fine  large  baby.  The  cord  was  very  thick,  and  did  not  separate  until  the  seventh 
day.  Before  the  separation  a  visitor  had  seized  hold  of  the  front  of  the  child's 
clothing,  and  after  that  time  the  navel  had  been  inclined  to  weep.  The  bleeding 
was  more  severe  on  the  thirteenth  day.  The  umbilicus  was  dusted  with  tannic 
acid.  On  September  30th  the  bleeding  continued.  On  October  1st  the  hemorrhage 
was  profuse.  The  child  died  at  5  a.  m.  October  2d.  During  the  illness  it  was  noted 
that  the  elbows  and  ankles  were  becoming  discolored. 

Case  2  .  —  A  female  child,  eight  days  old,  seen  on  December  19th.  She  was 
the  tenth  child.  The  umbilical  cord  had  not  come  away.  The  clothes  were  stained 
with  blood,  and  the  child  was  blanched.  Above  the  umbilicus  for  one  inch  the 
surface  was  red  and  the  skin  abraded.  The  blood  was  oozing  from  this  area,  and 
also  welling  from  the  umbilical  scar.  Styptics  were  of  no  avail.  Two  harelip  pins 
stopped  the  bleeding.  Two  days  later,  however,  the  bleeding  again  commenced, 
and  the  child  died  three  days  after  the  onset  of  the  hemorrhage. 

Case    3  .  —  November  10,   1887,  male  child,  ten  days  old.     This  was  the 

*  Garcin,  R.  D.:  Virginia  Med.  Semi-Monthly,  vii,  April,  1902-March,  1903,  376. 

t  Sibert,  D.  E.:   Arch,  of  Pediatrics,  1884,  i,  307. 

t  Taylor,  James:  Bristol  Med.  and  Chir.  Jour.,  1893,  xi,  237. 


112  THE    UMBILICUS    AND    ITS    DISEASES. 

twelfth  child.  The  cord  came  away  on  the  seventh  day.  On  November  10th  a 
patch  of  dark-colored  blood  was  noted  on  the  dressing  from  the  navel.  On  Novem- 
ber 12th,  a  bruise  was  detected  on  the  shoulder.  In  this  case  the  child  was  well  six 
years  later. 

Taylor  says  this  disease  appears  to  be  more  common  in  male  children,  and  that 
the  tendency  to  hemorrhage  is  transmitted  through  the  female  members  of  the 
same  family. 

Fatal  Umbilical  Hemorrhage  in  the  New-born.*  —  A 
woman,  who  had  been  weakened  greatly  by  several  pregnancies  occurring  in  rapid 
succession,  developed  jaundice,  and  her  child  was  delivered  four  weeks  too  soon. 
The  woman  died  several  hours  later  from  hemorrhage. 

The  child  was  weak.  Forty-eight  hours  after  birth  it  developed  jaundice.  It 
did  not  take  the  breast  well.  In  the  night  between  the  third  and  fourth  days 
bleeding  came  on  in  the  umbilical  region,  from  between  the  cord  and  the  umbilicus. 
The  child  died. 

Hemorrhage  From  the  Umbilical  Cord  on  the  Tenth 
Day  .f — ■  The  baby  was  ten  days  old.  Two  hours  before  Stuart  saw  him  there 
had  been  a  hemorrhage  from  the  umbilicus.  The  cord  in  this  case  had  come  off  on 
the  fifth  or  sixth  day,  and  blood  was  oozing  and  welling  up  drop  by  drop  from  the 
apparently  non-ulcerated  but  healthy-looking  stump.  Stuart  says:  "It  reminded 
one  of  the  water  bubbling  through  sand  at  the  bottom  of  a  spring;  only  the  oozing 
and  welling  up  from  the  stump  of  the  cord  were  very  deliberate  and  slow." 

Monsel's  solution,  silver  nitrate,  powdered  tannic  acid  with  subsulphate  of  iron, 
and  transfixion  of  the  stump  were  tried,  but  with  no  result.  The  child  died  the 
next  morning.  Stuart  says:  "A  remarkable  feature  of  this  case  was  the  location 
of  the  collateral  hemorrhage  in  the  eyes,  from  the  conjunctival  mucous  membrane, 
when  the  bleeding  seemed  to  be  controlled  for  a  time  at  the  umbilicus." 


UMBILICAL  HEMORRHAGE  IN  PATIENTS  AFTER  INFANCY. 

We  have  records  of  two  cases,  one  reported  by  Strecker  and  one  by  Colombe. 
Strecker's  patient  was  a  small,  pale  lad  of  eleven,  who  two  days  after  jumping 
down  a  short  distance  was  seized  with  bleeding  from  the  umbilicus,  associated  with 
alarming  abdominal  symptoms.  As  the  patient  recovered,  the  cause  of  the  bleed- 
ing was  never  discovered. 

Colombe's  patient  was  a  woman  thirty-six  years  old.  She  had  a  small  nodule 
at  the  umbilicus,  and  from  it  severe  bleeding  took  place.  The  bleeding  ceased  with 
the  removal  of  the  nodule. 

Umbilical  Hemorrhage  at  Eleven  Years  of  Age.J  — 
John  S.,  aged  eleven,  a  small,  pale,  blond  boy,  on  March  9,  1902,  jumped  from  a 
porch  floor  to  the  ground, — about  three  feet, — but  felt  no  ill  effects.  On  March 
11th  he  complained  of  pain  at  the  navel,  and  blood  was  discovered  coming  from  it. 
The  umbilicus  with  the  surrounding  tissue  for  one  inch  was  much  higher  than  the 
rest  of  the  abdominal  wall.     An  elastic  truss  was  applied.     On  March  12th  there 

*  Sadler:  Todtliche  Blutung  aus  dem  Umfange  des  Nabels  bei  einem  Neugeborenen. 
Schmidt's  Jahrb.,  1840,  xxvii,  177. 

t  Stuart,  A.  R.:  The  Medical  News,  1895,  Ixvi,  159. 
t  Strecker,  J.  E.:  The  Medical  World,  1903,  xxi,  211. 


UMBILICAL   HEMORRHAGE.  113 

was  another  umbilical  hemorrhage,  and  the  abdomen  was  markedly  distended, 
almost  to  the  bursting  point.  Opiates  were  given.  The  patient  vomited  bile, 
mucus,  and  fecal  matter,  and  was  in  a  state  of  collapse.  On  March  13th  the  ab- 
domen was  less  tense,  but  at  4  p.  m.  there  was  a  still  more  alarming  hemorrhage. 
Calcium  chlorid  was  given.  On  March  15th  an  operation  was  contemplated,  but  was 
put  off,  as  the  patient  was  better.  On  March  25th  the  patient  seemed  well.  In  this 
case  there  may  have  been  hemorrhage  into  the  abdomen  coming  through  the  um- 
bilical opening.  As  the  patient  recovered  and  no  operation  was  performed,  it  is 
impossible  to  determine  the  nature  of  the  case  with  absolute  certainty. 

A  Small  Vascular  Tumor  at  the  Umbilicus;  Hemor- 
rhage. Recovery.*  —  This  patient  was  a  woman  thirty-six  years  of  age. 
She  was  in  good  health  and  had  had  a  child  at  nineteen.  About  ten  years  before 
admission  the  patient  had  noticed  a  small  tumor,  the  size  of  a  grain  of  wheat,  at 
the  umbilicus.  This  had  gradually  increased  in  diameter.  It  was  purple,  rather 
soft,  painless,  but  inconvenient.  About  a  week  before  her  admission  it  was  the 
size  of  the  end  phalanx  of  the  little  finger. 

Two  years  before  coming  under  observation  there  had  been  hemorrhage  from 
the  tumor.  The  blood  had  come  in  jets.  This  bleeding  had  lasted  for  two  days, 
but  had  not  been  continuous,  and  had  been  controlled  with  iron  perchloric!.  Three 
days  before  admission  she  had  had  a  second  hemorrhage.  Perchlorid  of  iron  was  again 
used.  The  volume  of  the  tumor  could  be  compressed  to  the  diameter  of  the  femoral 
artery,  and  the  bleeding  was  intermittent.  The  patient  was  in  a  sea  of  blood. 
She  was  pale  and  apparently  in  a  serious  condition.  Forceps  were  applied,  and  the 
area  ligated  en  masse,  but  control  was  difficult,  as  the  bleeding  was  from  the  bottom 
of  the  umbilicus.  Seven  days  later  bleeding  occurred  again.  A  new  ligature  was 
applied,  and  the  bleeding  stopped  and  never  returned.  The  tumor  disappeared. 
The  origin  of  this  condition  remained  unknown. 


HEMATOMA  OF  THE  ABDOMINAL  WALL  NEAR  THE  UMBILICUS. 

This  condition  is  exceptional.  Hartz,  after  giving  a  splendid  resume  of  the 
various  methods  of  treating  the  umbilical  cord,  says  that  Westphalen  mentions  a 
hematoma  of  the  umbilicus  due  to  a  double  rupture  of  the  umbilical  vein. 

On  January  10,  1903,  in  consultation  with  Dr.  Thomas  Linthicum,  I  saw  a 
middle-aged  woman  who  had  a  marked  cardiac  lesion,  which  had  been  associated 
with  swelling  of  the  extremities  and  with  dropsy.  She  also  gave  a  definite  history 
of  gall-stones.  In  April,  1902,  she  had  had  erysipelas  which  had  lasted  four  weeks, 
and  shortly  afterward  had  had  swelling  of  the  wrists  and  noticed  an  abdominal 
enlargement.  Two  weeks  later  jaundice  developed,  which  lasted  three  or  four 
weeks.  About  this  time  cardiac  symptoms  were  noted.  Later  on  she  was  seized 
with  a  violent  pain  in  the  left  leg,  which  lasted  several  hours  and  then  extended  to 
the  right  leg,  reaching  from  the  hip  to  the  toes.  Dr.  Wells  said  that  the  circulation 
had  stopped  in  the  leg.  When  Dr.  J.  M.  T.  Finney  saw  her  a  few  days  later  pulsa- 
tion was  again  perceptible  in  the  leg,  but  he  agreed  with  Dr.  Wells  that  the  trouble 
was  in  the  arterial  circulation.  The  patient  was  ill  for  weeks,  and  when  she  was 
able  to  sit  up,  the  limbs  became  markedly  swollen.     On  December  15,  1902,  she 

*  Colombe:    Tumeur   vasculaire  de  l'ombilic;    hemorrhagie,  guerison.  Gaz.  med.  de   Paris; 
1887,  lviii,  245. 
9 


114  THE    UMBILICUS    AND    ITS    DISEASES. 

was  seized  with  a  severe  pain,  which  seemed  to  be  in  the  region  of  the  liver,  and  on 
December  18  she  was  thought  to  be  dying.  After  the  circulation  stopped  in  the 
leg  black  spots,  evidently  subcutaneous  hemorrhages,  developed.  These  were 
noted  from  time  to  time,  but  were  most  marked  in  December.  They  varied  in 
size  from  that  of  a  cent  to  that  of  two  hands.  A  gradual  improvement  followed, 
until  she  was  admitted  to  the  hospital  for  operation. 

When  I  saw  her,  just  above  and  to  the  right  of  the  umbilicus  was  a  deep-seated 
and  apparently  cystic  mass,  fully  16  cm.  in  diameter.  On  January  15th  the  patient 
was  removed  to  Baltimore.  She  stood  the  journey  poorly,  but  under  ether  the 
pulse  became  more  regular. 

An  incision  was  made  to  the  outer  side  of  the  right  rectus,  directly  over  the 
center  of  the  cystic  mass.  The  swelling  was  due  to  a  large  hematoma  between  the 
transversalis  fascia  and  the  peritoneum.  The  cavity  was  irregularly  circular,  and 
had  numerous  little  bays  running  off  in  all  directions.  The  walls  and  floor  of  the 
sac  were  thickened,  and  consisted  of  granulation  tissue.  The  cavity  was  filled  with 
dark,  clotted  blood.     I  packed  this  cavity  loosely  with  iodoform  gauze. 

An  incision  was  now  made  to  the  left  of  the  median  line,  and  curved  upward  to 
the  right.  After  the  gall-bladder  adhesions  had  been  separated  two  gall-stones, 
each  about  5  mm.  in  diameter,  were  removed,  and  the  gall-bladder  was  drained. 
The  hematoma  cavity  rapidly  granulated  and  closed  completely.  The  gall- 
bladder wound  also  closed,  and  the  patient  was  discharged  in  a  relatively  good 
condition. 

I  have  given  the  symptoms  somewhat  fully  in  order  that  the  reader  may  see  that 
the  cardiovascular  system  was  in  such  a  condition  that  a  rupture  of  one  of  the  blood- 
vessels was  much  more  prone  to  occur  than  in  a  healthy  individual.  This  hema- 
toma had  undoubtedly  been  due  to  a  rupture  of  either  an  artery  or  a  vein. 

In  a  personal  communication  dated  Sydney,  Australia,  March  14,  1911,  Dr. 
Fiaschi  tells  me  that  his  father  had  a  very  interesting  case  just  before  Christmas, 
1910.  A  young  woman  developed  a  hematoma  of  the  left  rectus  above  the  umbili- 
cus during  or  just  after  labor.  She  came  from  the  country,  and  Dr.  Fiaschi  and  his 
father  thought  prior  to  operation  that  they  might  find  a  ruptured  or  suppurating 
hydatid  of  the  abdominal  wall  or  of  the  left  lobe  of  the  liver. 


LITERATURE  CONSULTED  ON  UMBILICAL  HEMORRHAGE. 

Chartier:  Omphalorragie  grave,  traitement  par  le  serum  gelatine,  guerison.  Arch,  de  med.  des 
enfants,  1905,  viii,  477. 

Colombe:  Tumeur  vasculaire  de  l'ombilic;  hemorrhagic,  guerison.  Gaz.  med.  de  Paris,  1887, 
lviii,  245. 

Craig,  C.  F.:  Umbilical  Hemorrhage,  Etiology,  Pathology,  and  Treatment.  The  Medical  News, 
Phila.,  1894,  lxv,  569. 

Cumston,  C.  G. :  Infection  of  the  Umbilicus  in  the  Newly  Born.  New  York  and  Phila.  Med. 
Jour.,  1905,  lxxxi,  81. 

Fry,  Henry:   Omphalorrhagia  Neonatorum.    Amer.  Jour.  Obst.,  1907,  lv,  856. 

Gallant,  A.  E. :  Disorders  of  the  Umbilicus  with  Special  Reference  to  the  New-born  and  the  In- 
fant— III.     Umbilical  Infections.    Internat.  Clinics,  1907,  17th  series,  i,  151. 

Garcin,  R.  D.:  Fatal  Secondary  Hemorrhage  From  the  Umbilicus  Eight  Days  After  Birth.  Vir- 
ginia Med.  Semi-Monthly,  vii,  April,  1902-March,  1903,  376. 

Hartz,  A.:  Abnabelung  und  Nabelerkrankung.     Monatsch.  f.  Geb.  u.  Gyn.,  1905,  xxii,  77. 

Kommerell:  Ueber  Nachblutungen  bei  unterbundener  Nabelschnur.  Aerztl.  Rundschau,  Mlin- 
chen,  1896,  vi,  627. 


UMBILICAL   HEMORRHAGE.  115 

Reichard,  V.  M.:  Spontaneous  Hemorrhage  of  the  New-born  with  Recovery.     Jour.  Amer.  Med. 

Assoc,  October  26,  1912,  1539. 
Runge:   Die  Wundinfectionskrankheiten  der  Neugeborenen.    Die  Krankheiten  der  erst  en  Lebens- 

tage.    Stuttgart,  1893,  56. 
Sadler:   Todtliche  Blutung  aus  dem  Umfange  des  Nabels  bei  einem  Neugeborenen.     Schmidts 

Jahrb.,  1840,  xxvii,  177. 
Sibert:  A  Case  of  Fatal  Umbilical  Hemorrhage.    Arch,  of  Pediatrics,  1884,  i,  307. 
Strecker,  J.  C:   Umbilical  Hemorrhage  at  Eleven  Years  of  Age.     Med.  World,  1903,  xxi,  211. 
Stuart,  A.  R.:    Hemorrhage  From  the  Umbilical  Cord  on  the  Tenth  Day.     The  Med.  News, 

1895,  lxvi,  159. 
Taylor,  J.:  Three  Cases  of  Umbilical  Hemorrhage  Occurring  in  the  Same  Family,    ©ristol  Med. 

and  Chir.  Jour.,  1893,  xi,  237. 


CHAPTER  V. 
GRANULATION  TISSUE  OR  GRANULOMA  OF  THE  UMBILICUS. 

General  description. 
Differential  diagnosis. 
Treatment. 

Without  doubt  this  is  the  most  frequent  umbilical  abnormality  met  with, 
and  probably  every  physician  in  general  practice  has  at  some  time  noted  the  presence 
of  a  small  red  mass  in  the  umbilical  depression  shortly  after  the  cord  has  come  away. 

In  England  attention  has  been  drawn  to  the  subject  by  Millar,  in  Germany  by 
Ledderhose,  Pernice,  and  others;  in  France  the  subject  has  been  interestingly 
handled  by  Lannelongue  and  Fremont,  Forgue  and  Riche,  and  by  Florentin; 
in  the  American  literature  we  find  articles  on  the  subject  by  Holt  and  by  de  Villiers. 

Immediately  or  shortly  after  the  cord  comes  away,  a  slightly  purulent  or  yel- 
lowish discharge  may  be  noted  at  the  umbilicus,  and  on  separation  of  the  umbilical 
folds  a  small  red  tumor  mass  is  seen  on  the  umbilical  floor.  It  is  usually  the  size 
of  a  pea,  more  or  less  pedunculated,  light  or  dark  red  in  color,  has  a  rather  smooth, 
glistening  surface,  and,  although  sometimes  firm,  is  generally  soft  and  mushy  and 
may  bleed  readily.  It  is  nothing  more  than  typical  granulation  tissue.  It  repre- 
sents that  portion  of  the  umbilical  cord  distal  to  the  ligature,  which  in  the  process 
of  separation  has  not  completely  come  away. 

On  histologic  examination  the  entire  mass  is  found  to  consist  of  young  granula- 
tion tissue.  Its  blood  capillaries  are  very  abundant  and  scattered  throughout  the 
field  are  many  small  round-cells.  In  4  out  of  27  cases  collected  by  Pernice  the  sur- 
face of  the  granulation  was  partly  covered  over  with  a  delicate  epithelium. 

Millar  has  pointed  out  that  the  superficial  cells  of  the  granulation  tissue  may  be 
so  flattened  that  they  produce  a  quasi-epithelial  covering. 

These  small  tumors,  consisting  of  granulation  tissue,  were  formerly  often  con- 
fused with  another  small  umbilical  tumor  found  immediately  or  shortly  after  the 
cord  has  come  away.  These  nodules,  however,  are  very  firm,  are  not  apt  to  dis- 
appear, and  are  remnants  of  the  omphalomesenteric  duct.  With  a  little  practice 
the  two  varieties  can  be  readily  differentiated  clinically.  The  chief  points  of  dif- 
ference are  discussed  in  the  chapter  on  Umbilical  Polyp  (c/.  p.  124). 

I  append  the  report  of  a  case  of  a  small  granulation  tumor  at  the  umbilicus  that 
came  under  my  notice  in  consultation  with  Dr.  George  L.  Wilkins,  December  31, 1910: 

Granuloma  or  Granulation  Tissue  at  the  Umbilicus. 
—Baby  A.  The  child  was  two  months  old.  The  mother  said  that,  when  the  cord 
was  tied,  the  midwife  noted  that  it  was  very  much  larger  than  usual  at  the  umbilicus. 
A  Her  the  cord  came  away  there  was  an  abundant  discharge  of  what  the  mother 
said  was  corruption.  This  had  been  very  free  until  a  short  time  previously. 
The  umbilical  margins  were  raised  fully  2  mm.  from  the  surface  (Fig.  65).  In  the 
center  was  a  little  red  mass,  globular  in  form,  which  showed  a  whitish  mottling, 
just  as  if  there  were  a  mucosa  with  areas  of  skin  covering  it  at  certain  points.  It 
lay  directly  in  the  center  of  the  umbilicus.  Dr.  Wilkins  had  from  time  to  time 
applied  nitrate  of  silver.     The  nodule  had  diminished  somewhat  in  size.     It  was 

116 


GRANULATION    TISSUE    OR    GRANULOMA    OF    THE    UMBILICUS.  117 

removed  without  much  difficulty,  and  found  to  be  exceedingly  friable.  Histologic 
examination  showed  that  it  was  composed  entirely  of  granulation  tissue.  There 
was  no  evidence  at  any  point  of  an  epithelial  covering. 

Treatment  .  —  In  some  cases  it  will  suffice  to  snip  off  the  excessive  granu- 
lation tissue  with  the  scissors,  and  then  apply  an  astringent.  On  account  of  the 
smallness  of  the  umbilical  opening  it  is  usually  better  merely  to  apply  an  astringent 
and  then  keep  the  parts  dry.  The  granulation  tissue  then  soon  dries  up  and  drops  off. 
It  is  sometimes  possible  to  tie  off  the  granulation  mass,  but,  as  a  rule,  it  is  too  mushy. 


Fig.  65. — Ax  Umbilical  Gra.nttla.tiom. 
The  umbilical  ring  is  unusually  prominent,  protruding  at  least  2  mm.  above  the  abdominal  wall.     In  the  center 
is  a  small,  globular,  red  mass.     It  was  very  friable,  was  readily  removed,  and  did  not  recur.     On  histologic  examina- 
tion it  was  found  to  consist  essentially  of  young  granulation  tissue  rich  in  blood-capillaries.     It  contained  no  epithelial 
elements. 


LITERATURE  CONSULTED  ON  GRANULATION  TISSUE  OR  GRANULOMA  OF  THE 

UMBILICUS. 

Florentin,  P.:   Fungus  de  l'ombilic,    chez   le  nouveau-ne  et  chez  1' enfant.     These  de  Nancy, 
1908-9,  Xo.  22. 

Forgue  et  Riche:   Montp?ll.  med.,  1907,  xxiv,  145-169. 

Holt,  L.  Emmett:  Umbilical  Tumor  in  an  Infant  formed  by  Prolapse  of  the  Intestinal  Mucous 
Membrane  of  Meckel's  Diverticulum.    Med.  Record,  1888,  xxxiii,  431. 

Lannelongue  et  Fremont:    De  quelques  varietes  de  tumeurs  congenitales  de  l'ombilic  et  plus 
specialement  des  tumeurs  adenoides  diverticulaires.     Arch.  gen.  de  med.,  1884,  7e  ser.,  xiii,  36. 

Ledderhose,  G.:   Deutsche  Chirurgie,  1890,  Lieferung  45b. 

Millar,  W.  Heptinstall:   Umbilical  Polypi.     St.  Thomas's  Hospital  Reports,  New  Series,  xix,  287. 

Pernice,  L.:    Die  Xabelgeschwlilste,  Halle,  1892. 

de  Villiers,  J.  H.:  The  Nature  of  Umbilical  Growths  of  Infants  and  Young  Children.     Pediat- 
rics, 1897,  hi,  337. 


CHAPTER  VI. 
REMNANTS  OF  THE  OMPHALOMESENTERIC  DUCT. 

General  consideration. 
Umbilical  polyp. 

Historical  sketch. 

Symptomatology. 

Macroscopic  appearance  of  the  tumor. 

Microscopic  appearance  of  the  tumor. 

Multiple  umbilical  polyps. 

Differential  diagnosis. 

Treatment. 

Cases  in  which  umbilical  polyps  have  been  noted. 

These  comprise  one  of  the  most  interesting  groups  of  pathologic  conditions 
found  in  the  umbilical  region.  The  literature  on  the  subject  is  abundant,  many- 
authors  having  studied  and  described  more  or  less  in  detail  remnants  of  one  or 
more  portions  of  the  omphalomesenteric  duct.  Among  the  more  important  ar- 
ticles dealing  with  the  subject  are  those  of  Cazin  (1862),  Roth  (1881),  Tillmanns 
(1882),  Fitz  (1884),  Barth  (1887),  Zumwinkel  (1890),  Pernice  (1892),  Deschin 
(1895),  Ophuls  (1895),  Kirmisson  (1898),  Morian  (1899),  and  Florentin  (1908). 

In  the  following  pages  I  shall  discuss  at  some  length  the  various  remnants  of 
the  omphalomesenteric  duct  that  have  been  described  in  the  literature,  and  shall 
also  deal  with  remnants  of  the  omphalomesenteric  vessels  as  they  have  been  noted 
at  operation  or  at  autopsy.  Barth,  Zumwinkel,  and  Morian  have  each  given  a 
scheme,  illustrating  the  various  remnants  of  the  omphalomesenteric  duct  that  have 
been  met  with.  After  a  thorough  survey  of  the  literature  I  have  amplified  to  some 
extent  the  schemes  heretofore  published. 

Umbilical  Polyps. — The  most  common  remnant  of  the  omphalomesenteric  duct 
is  a  small  red  polyp  noted  in  the  umbilical  depression,  when  the  cord  has  come 
away.  It  is  bright  red  in  color  and  secretes  mucus.  On  microscopic  examination 
its  outer  surface  is  seen  to  be  covered  with  mucosa  similar  to  that  of  the  small 
bowel,  and  its  center  is  composed  of  non-striped  muscle.  It  may  persist  for  years 
unless  tied  off  or  cut  off. 

There  is  a  group  of  small  umbilical  polyps  or  umbilical  fistulse  in  which  the  outer 
covering,  or  the  lining,  as  the  case  may  be,  consists  of  a  mucous  membrane  that 
secretes  a  fluid  more  or  less  similar  to  gastric  juice.  The  mucosa  itself  bears  a 
striking  resemblance  to  gastric  mucosa.  Only  a  few  of  these  cases  have  been  ob- 
served. 

The  outer  portion  of  the  omphalomesenteric  duct  may  remain  patent,  there 
being  evident  at  the  umbilicus  a  small  projection  into  which  a  probe  can  be  passed 
for  a  variable  distance.  The  projection,  and  also  the  canal  extending  into  the 
depth,  are  covered  or  lined  with  mucosa  similar  to  that  of  the  small  bowel. 

Meckel's  diverticulum  is  the  patent  inner  end  of  the  omphalomesenteric  or 
vitelline  duct.     It  usually  arises  from  the  convex  surface  of  the  bowel,  but  occa- 

118 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  119 

sionally  projects  from  the  mesenteric  border.  It  may  or  may  not  be  attached  to 
the  umbilicus.  The  various  forms  of  Meckel's  diverticulum  will  be  considered,  and 
then  the  complications  that  may  be  associated  with  its  presence. 

Intestinal  cysts  may  develop  in  various  ways.  Those  originating  from  a  portion 
of  the  omphalomesenteric  duct  may  be  situated  beyond  the  convexity  of  the  bowel; 
occasionally  they  lie  in  the  mesentery  of  the  ileum.  As  they  originate  from  the 
omphalomesenteric  duct,  they  are  lined  with  mucosa  similar  to  that  of  the  small 
bowel. 

A  review  of  the  literature  shows  that,  in  a  certain  number  of  cases,  as  soon  as 
the  cord  comes  away,  more  or  less  discharge  comes  from  an  opening  at  the  umbilicus. 
This  is  usually  due  to  a  patent  omphalomesenteric  duct.  The  opening  at  the  um- 
bilicus may  lie  in  the  umbilical  depression,  but  quite  frequently  there  is  at  the  um- 
bilicus a  reddish  projection,  in  the  center  of  which  is  the  opening  of  the  duct.  The 
amount  of  discharge  depends,  in  a  large  measure,  on  the  caliber  of  the  duct.  When 
this  is  small,  just  the  faintest  amount  of  colorless  or  brown,  watery  fluid  may  escape; 
on  the  other  hand,  if  the  opening  be  large,  feces  and  gas  escape.  Occasionally  the 
fistula  develops  on  the  side  of  the  cord  near  the  abdomen  before  the  ligature  drops 
off,  and  we  have  the  record  of  one  case  in  which  the  outer  end  of  the  omphalo- 
mesenteric duct  opened  into  the  abdominal  cavity  near  the  umbilicus.  In  this  case 
Orth  found  feces  in  the  abdominal  cavity  among  intestinal  loops. 

When  the  patent  omphalomesenteric  duct  is  of  relatively  large  caliber,  there  is 
a  tendency  for  the  small  bowel  to  prolapse  through  the  duct  and  turn  inside  out  on 
the  abdominal  wall,  forming  a  sausage-like  mass  on  the  exterior  of  the  abdomen. 
The  mass  assumes  various  shapes,  is  bright  or  dark  red  in  color,  and  at  either  end 
has  an  opening  corresponding  with  the  lumen  of  the  bowel  at  the  upper  and  lower 
end  of  the  prolapsed  loop.  This  prolapsus  may  occur  within  a  day  or  two  after 
birth  or  after  several  months.  When  this  complication  develops,  death  nearly 
always  speedily  follows. 

In  rare  instances  remnants  of  the  omphalomesenteric  duct  have  been  found 
between  the  peritoneum  of  the  abdominal  wall  and  the  muscles.  They  have  oc- 
curred as  small  cysts  which  sometimes  communicate  with  the  umbilical  depression. 
Naturally,  they  are  lined  with  mucosa  similar  to  that  of  the  small  bowel. 

Sometimes,  when  all  trace  of  the  omphalomesenteric  duct  has  disappeared, 
remnants  of  the  omphalomesenteric  vessels  still  persist.  These  may  extend  from 
the  mesentery  of  the  small  bowel  to  the  umbilicus,  or  be  recognized  as  free  fila- 
ments attached  either  to  the  umbilicus  or  to  the  mesentery.  These  remnants, 
by  becoming  adherent  to  some  structure,  occasionally  cause  intestinal  obstruction. 

After  this  brief  summary  dealing  with  the  remnants  of  the  omphalomesenteric 
duct  or  its  vessels  that  may  be  found,  we  shall  consider  each  abnormality  in  detail. 
The  various  remnants  of  the  omphalomesenteric  duct  are  as  follows : 

Umbilical  polyps. 

Gastric  mucosa  at  the  umbilicus. 

A  patent  outer  portion  of  the  omphalomesenteric  duct. 

Meckel's  diverticulum. 

Intestinal  cysts. 

A  patent  omphalomesenteric  duct. 

A  patent  omphalomesenteric  duct  opening  at  birth  on  the  side  of  the  cord. 

A  patent  omphalomesenteric  duct  with  other  intestinal  lesions. 


120  THE    UMBILICUS    AND    ITS    DISEASES. 

A  prolapse  of  the  bowel  through  a  patent  omphalomesenteric  duct. 

Cysts  of  the  abdominal  wall. 

Remains  of  the  omphalomesenteric  vessels. 

LITERATURE  CONSULTED  ON  REMNANTS  OF  THE  OMPHALOMESENTERIC  DUCT 

IN  GENERAL. 
Barth,  A.:    L'eber  die  Inversion  des  offenen  Meckel'schen   Divertikels  und   ihre   Complication 

mit  Darmprolaps.     Deutsche  Ztschr.  f.  Chir.,  1887,  xxvi,  193. 
Cazin,  H.:  Etude  anatomique  et  pathologique  sur  les  diverticules  de  l'intestin.     These  de  Paris 

1862,  No.  138. 
Deschin:  Zur  Frage  der  chirurgischen  Behandlung  bei  dem  Vorfall  des  Dotterganges.     Centralbl . 

f.  Chir.,  1895,  xxii,  1154. 
Fitz,  Reginald  H. :    Persistent  Omphalomesenteric  Remains;    their  Importance  in  the  Causa- 
tion of  Intestinal  Duplication,  Cyst-formation,  and  Obstruction.     Amer.  Jour.  Med.  Sci., 

1884,  lxxxviii,  30. 
Florentin,  P.:    Fungus  de  l'ombihc,  chez  le  nouveau-ne  et  chez    l'enfant.      These    de   Nancy, 

1908-09,  No.  22. 
Kirmisson:     Maladies  congenitales   de  l'ombilic.      Traite  des  maladies   chirurgicales  d'origine 

congenitale,  Paris,  1898,  208. 
Morian:   Ueber  das  offene  Meckel'sche  Divertikel.     Langenbeck's  Arch.  f.  klin.  Chir.,  1899,  lviii, 

306. 
Ophiils,  W. :    Beitrage  zur  Kenntniss  der   Divertikelbildungen   am   Darmkanal.      Inaug.  Diss., 

Gottingen,  1895. 
Pernice,  Ludwig:   Die  Nabelgeschwtilste,  Halle,  1892. 
Roth,  M.:     Ueber   Missbildungen   im    Bereich   des    Ductus   omphalomesentericus.     Virchows 

Arch.,  1881,  lxxxvi,  371. 
Tillmanns,    H.:     Ueber   angeborenen    Prolaps    von    Magenschleimhaut    durch    den    Nabelring 

(Ectopia  ventriculi)  und  liber  sonstige    Geschwulste    und  Fisteln  des  Nabels.      Deutsche 

Ztschr.  f.  Chir.,  1882-83,  xviii,  161. 
Zumwinkel:    Subcutane  Dottergangscyste  des  Nabels.     Langenbeck's  Arch.  f.  klin.  Chir.,  1890, 

xl,  838. 

UMBILICAL  POLYPS. 

Incomplete  healing  of  the  umbilical  stump  is  not  of  very  rare  occurrence.  The 
tissue  is  dull  red  in  color,  rather  soft,  and  soon  disappears  after  the  use  of  astringents. 

Now  and  again,  after  the  cord  has  come  away,  a  small,  polyp-like  mass  is  found 
in  the  umbilical  depression  (Figs.  66,  67,  68,  and  91).  This  is  brighter  in  color 
than  the  ordinary  granulation  tissue,  and  is  unaffected  by  astringents. 

Brun,  in  1834,  reported  the  case  of  a  female  child,  three  years  old,  who  came 
under  Dupuytren's  care.  When  the  cord  came  away  on  the  eighth  or  ninth  day, 
a  tumor  was  noted.  It  was  the  size  of  a  cherry  and  had  a  mucous  surface.  It  was 
ligated  at  its  base,  and  dropped  off  five  days  later;  the  wound  healed.  Brun  says 
that  this  child's  sister  had  a  similar  nodule  at  the  umbilicus.  The  second  child 
died  when  four  and  one-half  years  old.  During  the  last  eight  months  of  her  life 
she  complained  continually  of  abdominal  pain. 

Fabrege,  in  1848,  reported  two  cases.  The  first  patient  was  a  boy,  one  month 
old.  The  mother  noticed  a  moisture  at  the  umbilicus  as  soon  as  the  cord  came 
away.  At  the  umbilicus  was  a  reddish,  pedunculated  tumor  the  size  of  a  pea. 
This  was  cut  away  with  scissors  and  the  base  cauterized.  The  growth  apparently 
returned.  It  was  again  treated  in  a  similar  manner,  and  the  umbilicus  then  re- 
mained healed.  His  second  case  was  in  a  baby  girl  three  weeks  old,  who  had  a  pea- 
sized  nodule  situated  in  the  umbilical  depression.     It  was  red,  bled  readily  on  being 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  121 

It  was  gradually  constricted  with  a  ligature 


touched,  and  had  a  definite  pedicle 
and  dropped  off  on  the  third  day. 


Polyp 


Fig.  66. — The  Grahcal  Atrophy  of  the  Omphalo- 
mesenteric Duct.  (Schematic.) 
The  outer  end  of  the  duct  is  closed  and  represented 
by  a  polyp-like  projection  which  is  covered  over  with 
intestinal  mucosa.  If  this  were  ligated,  when  the  liga- 
ture came  away,  a  patent  omphalomesenteric  duct 
would  undoubtedly  result.  The  duct  is  patent  from 
the  intestine  to  the  umbilicus.  For  the  subsequent 
stages  in  the  atrophy  of  the  omphalomesenteric  duct 
see  Figs.  67,  6S,  S9,  90,  and  91. 


Muscle 


Fig.  67. — An  Umbilical  Polyp  Connected  with 
Meckel's  Diverticulum  by  a  Fibrous  Cord. 
(Schematic.) 

The  umbilical  polyp  is  covered  with  intestinal  mu- 
cosa and  has  a  central  stem  composed  of  non-striped 
muscle  and  fibrous  tissue.  The  central  portion  of  the 
omphalomesenteric  duct  is  represented  by  a  fibrous 
cord,  the  inner  end  by  Meckel's  diverticulum.  This 
condition  has  been  noted  in  a  number  of  cases.  For 
further  atrophy  of  the  omphalomesenteric  duct  see 
Figs.  6S,  89,  90,  and  91. 


Simpson,  in  the  Obstetrical  Memoirs  and  Contributions,  published  in  Phila- 
delphia in  1856,  referred  to  a  case  that  he  saw  with 
Dr.  Findlay.  The  umbilical  excrescence  resembled 
a  cherry  in  size  and  color.  It  was  apparently  not 
painful  to  the  touch,  but  blood  oozed  from  its  sur- 
face on  handling.  Silver  nitrate  was  used  several 
times,  but  with  no  effect.  A  few  weeks  later  a  liga- 
ture was  applied  around  its  base  and  it  dropped  off 
in  a  few  days. 

Virchow,  in  1862,  in  referring  to  "fungus  of  the 
umbilicus,"  mentions  two  kinds:  the  more  common 
one  is  rich  in  blood-vessels,  bleeds  easily,  and  is 
found  after  the  cord  comes  away.  It  consists  of 
granulation  tissue.  It  soon  disappears  after  the 
use  of  astringents.  The  second  kind  of  tumor  is  a 
congenital  growth. 

Holmes,  in  his  "  Surgical  Treatment  of  Children's 
Diseases,"  published  in  London  in  1868,  says  that 
warty  or  nipple-like  tumors  projecting  from  the  um- 
bilicus are  f airly  often  seen  in  children,  and  that  they 
seem  to  be  due  to  some  morbid  condition  left  by 
separation  of  the  umbilical  cord.  He  gives  Athol 
Johnson  credit  for  the  first  reference  to  this  condi- 
tion noted  in  the  English  language.  Johnson  speaks 
of  it  as  a  stout,  nipple-shaped  papilla  or  tubercle  aris- 
ing from  the  center  of  the  main  umbilical  depression. 
Holmes  says  that  these  may  attain  the  height  of  an  inch 
none  as  large  as  this.     In  his  cases  the  tumors  were  ligated. 


Muscl. 


Fig.  68. — An  Umbilical  Polyp  At- 
tached to  the  Small  Bowel  by 
a  Fibrous  Cord.  (Schematic.) 
The  outer  end  of  the  omphalo- 
mesenteric duct  is  here  represented  by 
an  umbilical  polyp,  which  is  covered 
over  with  intestinal  mucosa  and  which 
consists  in  a  large  measure  of  non- 
striped  muscle.  A  slight  depression  in 
its  tip  is  all  that  remains  of  the  lumen 
of  the  duct.  In  the  majority  of  the 
cases  in  which  a  pol>-p  is  found,  all 
trace  of  the  cavity  has  disappeared. 
In  this  case  the  intra-abdominal  por- 
tion of  the  omphalomesenteric  duct  is 
represented  by  a  cord  extending  from 
the  umbilicus  to  the  convex  surface  of 
the  small  bowel.  It  is  the  possible 
existence  of  this  cord  that  must  always 
be  thought  of  in  patients  who  have,  or 
give  a  history  of  ever  having  had,  an 
umbilical  polyp. 


He  saw  several,  but 


122  THE    UMBILICUS    AND    ITS    DISEASES. 

While  all  the  foregoing  tumors  were  undoubtedly  umbilical  polyps,  Kolaczek 
seems  to  have  been  the  first  to  give  us  the  complete  picture  of  this  disease.  In 
1871.  under  the  title  "  Enteroteratoma  of  the  Umbilicus,"  he  reported  the  case  of  a 
boy  four  years  old  who  had  a  small  umbilical  tumor.  On  microscopic  examination 
it  was  found  that  the  outer  surface  of  the  tumor  was  covered  with  cylindric  epi- 
thelium, and  opening  on  the  surface  were  Lieberklihn's  glands,  while  between  the 
glands  were  lymphatic  tissue  and  connective  tissue.  The  center  of  the  nodule  was 
composed  of  smooth  muscle. 

In  1875  Kolaczek  reported  a  second  case,  which  presented  a  precisely  similar 
picture. 

Kustner,  in  1876,  reported  a  similar  case.  He  examined  a  fungus  removed  from 
the  umbilical  depression  of  a  three  months  old  child,  not  expecting  to  find  anything 
but  granulation  tissue,  and  was  not  a  little  surprised  to  note,  instead  of  this  simple 
structure,  a  relatively  complicated  picture.  In  the  center  was  connective  tissue; 
external  to  this  were  round  cells  and  granulation  tissue,  and  embedded  in  the  per- 
iphery, numerous  tubular  glands.  The  tumor,  which  was  the  size  of  a  pea,  was 
covered  with  beautiful  cylindric  epithelium. 

Parker,  in  the  Archives  of  Clinical  Surgery,  published  in  New  York  in  1876, 
reported  the  findings  in  a  boy  two  and  one-half  years  old.  Soon  after  birth  the 
parents  noticed  that  the  navel  did  not  heal.  There  was  a  hard  mass  situated  at  the 
connection  of  the  cord  with  the  abdominal  wall,  and  to  the  right  of  the  cord  a  naked, 
non-cicatrized  surface  discharging  a  thin  mucous  fluid.  The  area  failed  to  cicatrize, 
and  the  tumor  increased  in  size.  When  the  boy  was  three  years  old  an  attempt  was 
made  to  remove  the  growth,  but  only  part  was  taken  away,  as  it  extended  into  the 
abdomen.  Fifteen  months  later  the  tumor  was  harder  and  firmer  and  was  increas- 
ing in  size.  An  elliptic  piece  of  the  abdominal  wall  including  the  tumor  was  cut 
away,  and  the  child  made  a  good  recovery. 

Dr.  Alonzo  Clark  made  the  microscopic  examination  and  thought  the  growth 
was  a  cancer.  It  was,  however,  in  all  probability,  an  adenoma  or  polyp  of  the  ab- 
dominal wall. 

Since  that  time  isolated  cases  have  been  recorded.  Dr.  William  D.  Booker,  in  a 
very  large  pediatric  practice,  tells  me  that  he  has  observed  only  one  case.  As  will 
be  seen  from  the  accompanying  abstract  of  the  literature,  Giani  reports  4  cases 
and  Hue  5  cases. 

Symptomatology. 

Umbilical  polyps  are  usually  noted  when  the  cord  comes  away.  Some  have 
come  under  observation  during  the  first  few  weeks  of  the  child's  life;  others  have 
not  been  treated  until  the  child  was  several  months  old,  and  in  quite  a  number  of 
instances  not  until  it  was  from  three  to  eight  years  of  age.  Walther's  patient  was 
eighteen  years  old;  Hektoen's,  fifteen  years;  Stori's,  twenty  years;  Gernet's. 
twenty-four  years;  Hartmann's,  twenty-nine  years,  and  in  a  case  reported  by 
myself  the  patient  was  twenty  years  old. 

Apart  from  a  slight  umbilical  discharge  and,  where  the  tumor  was  rather  large, 
some  bleeding,  the  umbilical  nodules  have  given  rise  to  little  or  no  discomfort. 

Macroscopic  Appearances  of  the  Tumor. 
Those  small  tumors  in  the  majority  of  the  cases  are  not  larger  than  a  pea,  an 
olive-stone,  a  cherry,  or  a  grape.     In  a  few  cases,  however,  the  nodule  has  been  large. 


REMNANTS  OF  THE  OMPHALOMESENTERIC  DUCT. 


123 


In  Gernet's  case  it  reached  the  size  of  a  walnut,  measuring  2.5  cm.  x  2  cm.  Hek- 
toen's  was  2.5  cm.  long  and  3  cm.  in  its  greatest  circumference  (Fig.  70).  Wal- 
ther's  patient  had  a  tumor  2.5  cm.  long  and  2  cm.  broad.  In  Kirmisson's  patient 
the  tumor  reached  4  cm.  in  length. 

These  tumors  are  generally  bright  red  in  color,  but  occasionally  of  a  darker  hue. 
They  are  covered  over  with  a  smooth,  velvety  membrane  which  looks  like  intestinal 
mucosa.  Where  the  tumor  is  small  and  protected  by  the  umbilical  folds,  it  is  usually 
bright  red  and  smooth,  but  when  large,  it  rises  above  the  level  of  the  abdomen,  and 
as  a  result  of  the  rubbing  of  the  clothing  may  become  irritated. 

The  nodule  often  secretes  a  small  amount  of  alkaline  fluid.  This  is  mucus. 
When  irritation  has  occurred,  the  mucus  may  be  mixed  with  a  small  amount  of  pus. 

The  nodule  at  its  tip  is  usually  rounded  and  intact,  but  occasionally,  at  its  most 
prominent  point,  there  is  a  depression  into  which  a  probe  may  be  inserted  for  2  mm. 
or  more.  In  Sheen's  case  it  could  be  carried  one  inch  inward.  The  tumor  on 
palpation  is  firm  and  elastic  and  cannot  be  reduced  in  size.  Manipulation  some- 
times causes  slight  bleeding.  Although  some  of  these  polyps  are  sessile,  they  are 
more  apt  to  be  attached  to  the  center  of  the  um- 
bilical depression  by  a  definite  pedicle. 

The  skin  surrounding  the  umbilicus  is  usually 
normal.  In  Capette  and  Gauckler's  case,  how- 
ever, it  was  drawn  up  around  the  polyp,  forming 
a  definite  prepuce.  When  there  is  much  discharge 
from  the  polyp,  the  surrounding  skin  occasionally 
shows  some  reddening. 

In  Broca's  case,  and  also  in  the  one  recorded 
by  Capette  and  Gauckler,  there  was  a  small  um- 
bilical hernia  and  the  polyp  was  seated  upon  the 
summit  of  the  hernial  projection. 


Fig.  69. — An  Umbilical  Polyp  on  the 
Prominent  Part  of  an  Umbilical 
Hernia.      (Schematic.) 
Small  umbilical  hernia?  are  relatively 
common.     Umbilical  polyps  are  occasion- 
ally met    with.     The    combination  of    a 
polyp  on  the  top  of    a  hernia  has  been 
noted,  but  is  most  unusual. 


Microscopic  Appearance  of  the  Polyp. 

The  surface  of  the  polyp  is  covered  over  with 
typical  intestinal  mucosa.     The  external  layer  is 

composed  of  cylindric  epithelium,  and  opening  on  the  surface  are  tubular  glands 
(Fig.  74,  p.  133;  Fig.  75,  p.  134;  Fig.  76,  p.  135;  Fig.  123,  p.  207).  These  resemble 
Lieberkuhn's  glands,  but  occasionally  those  of  the  Brunner  type  are  also  present, 
and  now  and  then  glands  that  bear  a  striking  resemblance  to  those  of  the  pyloric 
end  of  the  stomach.  The  stroma  between  the  glands  is  similar  to  that  noted  in 
the  small  bowel.  The  central  portion  of  the  polyp  consists  of  non-striped  muscle 
and  connective  tissue. 

When  the  polyp  has  been  of  long  standing,  and  on  account  of  its  size  has  been 
subjected  to  contact  with  the  clothing,  the  surface  epithelium  may  be  lacking  and 
the  superficial  layers  of  the  mucosa  replaced  by  granulation  tissue. 

The  line  of  junction  between  the  mucosa  covering  the  polyp  and  the  squamous 
epithelium  of  the  umbilicus  is  usually  abrupt,  the  normal  skin  beginning  at  the  point 
where  the  intestinal  mucosa  ends  (Fig.  75,  p.  134;  Fig.  81,  p.  140). 

In  cases  in  which  a  channel  occupies  the  center  of  the  polyp  this  itself  is  lined 
with  intestinal  mucosa. 

From  the  above  it  is  seen  that  the  umbilical  polyp  is  covered  over  with  typical 


124  THE    UMBILICUS  AND    ITS    DISEASES.  , 

intestinal  mucosa.  It  is  a  remnant  of  the  outer  end  of  the  omphalomesenteric  duct, 
which  has  persisted  outside  the  abdominal  cavity.  When  the  cord  has  sloughed 
off,  the  remnant  contracts  down,  producing  the  polyp. 

Various  names  have  been  applied  to  these  growths — fungus,  enteroteratoma, 
adenoma,  and  polyp.  Such  a  growth  has  a  definite  structure,  and  should  not  be 
called  a  fungus.  Its  mode  of  origin  precludes  the  use  of  the  term  enteroteratoma, 
and,  as  Holt  has  pointed  out,  the  name  adenoma  is  not  correct.  Umbilical 
polyp  seems  to  be  the  most  suitable  name,  since  there  is  no  abnormality  at  the 
umbilicus  except  granulation  tissue  that  can  possibly  be  confused  with  it  clinically. 

Multiple  Umbilical  Polyps. 

Henke  reports  a  case  in  which  a  pea-shaped  umbilical  polyp,  5  mm.  long,  was 
divided  into  three  small  lobes.  Kirmisson,  in  the  examination  of  a  child  three 
years  old,  found  a  small  umbilical  tumor  which  also  consisted  of  three  lobes.  These 
were  situated  in  the  umbilical  cicatrix.  The  combined  tumor  was  the  size  of  a 
cherry. 

This  formation  of  several  lobes  is  of  no  significance.  The  explanation  is  that 
the  remnant  of  the  vitelline  duct  has  merely  split  off  into  several  pieces  instead  of 
forming  one  sharply  defined  and  intact  nodule. 

Differential  Diagnosis. 

Granulation  Tissue.  Umbilical  Polyp. 

Found  only  during  the  first  few  weeks.  May  persist  for  years. 

Dull  red,  or  pink.  Bright  red  in  color. 

Soft.  Firm  and  resistant. 

A  purulent  secretion  is  present.  Secretes  mucus  unless  the  surface  has  become 

irritated — then  mucopus. 
Disappears  after  the  use  of  astringents.  Usually  not  affected  by  astringents. 

Consists  of  typical  granulation  tissue.  Has   an   outer   covering   of   intestinal  mucosa 

and    a    center    consisting    of    non-striped 

muscle. 
Usually  disappears  in  a  few  months.  Persists  until  removed. 

From  this  tabulation  it  is  seen  that,  both  clinically  and  histologically,  the  dif- 
ferences between  granulation  tissue  and  umbilical  polyps  are  so  sharp  that  a  diag- 
nosis can  usually  be  readily  made. 

Treatment. 

Silver  nitrate  and  other  caustics  have  often  been  used  with  no  effect. 

In  many  of  the  cases  the  tumor  was  simply  ligated  and  dropped  off  in  a  few  days ; 
in  others  it  was  ligated  and  cut  off  at  once.  If  only  a  portion  of  the  growth  is  re- 
moved, the  remainder  will,  of  course,  persist,  and  possibly  increase  a  little  in  volume. 
In  some  of  these  polyps  the  omphalomesenteric  artery  still  persists,  hence  the  neces- 
sity for  careful  ligation  of  the  pedicle  of  the  polyp.  This  vessel  persisted  in  Lanne- 
longue  and  Fremont's  Case  2. 

In  a  certain  percentage  of  the  cases  when  an  umbilical  polyp  is  present,  other 
portions  of  the  omphalomesenteric  duct  also  persist  (Figs.  66,  67,  68,  90).  In 
Lowenstein's  case,  for  example,  after  the  umbilical  polyp  had  been  cut  away,  it  was 
found  that  the  omphalomesenteric  duct  near  the  bowel  was  patent.  Here  it  was 
6  mm.  in  diameter. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  125 

In  Hartmann's  patient,  a  man  of  twenty-nine,  a  typical  umbilical  polyp  was 
present.  The  man  gradually  developed  definite  signs  of  intestinal  obstruction. 
Hartmann,  on  opening  the  abdomen,  found  the  small  bowel  dilated  and  injected. 
The  obstruction  was  due  to  a  partially  patent  omphalomesenteric  duct.  Meckel's 
diverticulum  was  markedly  compressed  at  its  insertion  into  the  small  bowel.  The 
diverticulum  was  6  mm.  in  diameter  and  4  cm.  long.  From  that  point  to  the  ab- 
dominal wall  it  was  continued  as  a  fibrous  cord  which  terminated  in  the  umbilical 
polyp. 

In  every  case  of  umbilical  polyp  it  is  the  duty  of  the 
family  physician  or  surgeon  to  explain  carefully  to  the 
parents  the  possible  coexistence  of  an  intra-abdominal 
portion  of  the  omphalomesenteric  duct,  which  may  be 
adherent  to  the  umbilicus  and  later  give  rise  to  intes- 
tinal obstruction.  The  parents  should  be  instructed 
to  watch  such  children  carefully,  and  if  in  later  life 
the  slightest  sign  of  intestinal  obstruction  develops, 
an  abdominal  operation  should  be  immediately  under- 
taken, the  surgeon  making  an  incision  encircling  the 
umbilicus  and  looking  immediately  for  an  adherent 
Meckel's   diverticulum. 

Cases  in  which  Umbilical  Polyps  have  been  Noted. 

That  the  literature  on  the  subject  is  relatively  small  is  evidently  due  in  part  to 
the  fact  that  these  small  polyps  often  give  rise  to  but  little  inconvenience.  Most 
of  those  who  have  had  much  to  do  with  children  have  observed  one  or  more  cases. 

A  Case  of  Umbilical  Polyp.*  — -A  child,  six  months  old,  had  a 
small  growth  at  the  umbilicus.  It  was  deep  red  in  color,  had  a  granular-looking 
surface,  and  was  attached  to  the  umbilicus  by  a  narrow  pedicle.  The  growth  was 
ligated  by  Dr.  Falkiner  and  cut  away.  On  microscopic  examination  Ball  found 
that  the  pedicle  consisted  of  muscle.  Covering  the  outer  surface  was  glandular 
tissue  with  adenoid  tissue  between  the  glands.  The  glands  closely  resembled  those 
of  the  stomach.     This  case  appeared  to  be  one  of  simple  umbilical  polyp. 

An  Umbilical  Polyp.  —  Bidonef  reports  the  case  of  a  child  two  years 
old,  in  which  a  small  umbilical  growth  had  been  noted  after  the  cord  came  away. 
This  little  growth  was  removed  with  the  thermocautery.  It  was  a  typical  intes- 
tinal polyp.  Bidone  gives  very  good  pictures  of  the  case,  and  also  a  resume  of  the 
literature. 

Umbilical  Polyp.  —  Blanc  and  Weill  report  two  small  tumors  of  the 
umbilicus.  The  larger  was  the  size  of  a  pea.  Both  were  pedunculated.  Many 
of  the  glands  covering  them  resembled  Lieberkuhn's  glands.  The  tumors  were 
remains  of  the  omphalomesenteric  duct. 

Adenoid    Tumors.  —  With  regard  to  the  etiology,  Blanc, §  working  in 

*  Ball,  C.  B.:  Illustrated  Med.  News,  18S9,  iv,  149. 

t  Bidone,  E.:  Enteroteratonia  ombelicale.  Bull,  delle  scienze  med.,  Bologna,  1901,  ser.  S,  i, 
374. 

I  Blanc  and  Weil:  Paris  Anatomical  Society,  1899.  Rev.  in  Centralbl.  f .  allg.  Path.  u.  path. 
Anat.,  1900,  xi,  748. 

§  Blanc,  H. :  Contribution  a,  la  pathologie  du  diverticule  de  Meckel.  These  de  Paris,  1899, 
No.  393. 


126  THE    UMBILICUS    AND    ITS    DISEASES. 

Broca's  service,  says  that  in  16  cases  there  was  granulation  of  the  umbilicus,  but 
after  personal  examination  of  two  of  the  cases  he  found  the  tumors  to  be  adenoma- 
tous, suggesting  that  they  had  originated  from  Meckel's  diverticulum.  They 
appeared  in  the  umbilical  region  following  birth,  immediately  after  the  cord  had 
come  away.  Such  tumors  are  congenital.  They  vary  in  volume  from  the  size  of  a 
cherry  to  that  of  a  pea.  They  are  solid  in  consistence,  and  occupy  the  center  of  the 
umbilicus. 

Blanc  then  goes  on  to  report  two  cases  that  he  had  observed.  These  resembled 
in  practically  every  particular  the  small  glandular  bodies  so  often  noted.  He  ends 
with  an  able  discussion  of  diverticula. 

An  Umbilical  Polyp.  —  Dr.  Wm.  D.  Booker,*  of  Baltimore,  said  that 
in  all  his  experience  he  had  encountered  only  one  case  of  adenoma  or  polypoid 
outgrowth  from  the  umbilicus.  A  section  showed  that  it  was  covered  over  exter- 
nally with  characteristic  intestinal  mucosa. 

Polyp  of  the  Umbilicus,  f  —  In  Broca's  clinic  a  boy,  two  months 
old,  had  a  small  polypoid  mass  the  size  of  a  pea  implanted  on  the  surface  of  an  um- 
bilical hernia.  The  hernia  was  about  the  size  of  the  little  finger.  The  tumor  was 
segmented  and  projected  about  2  cm.  from  the  surface  of  the  umbilicus;  it  was 
reddish  in  color.  This  polyp  was  noted  on  the  fourteenth  day,  i.  e.,  three  days  after 
the  cord  had  come  away.     Broca  cut  it  off  with  scissors. 

An  Umbilical  Polyp.  %  —  A  girl,  three  years  old,  came  under  Du- 
puytren's  care.  The  cord  came  away  on  the  eighth  or  ninth  day,  and  the  tumor, 
the  size  of  a  cherry,  was  then  noted.  It  had  a  mucous  surface  but  no  fistulous 
opening.  It  was  tied  off  with  silk  at  its  base.  It  dropped  off  on  the  fifth  day  and 
the  umbilicus  healed. 

Brun  says  that  this  child's  sister  had  had  a  similar  nodule  at  the  umbilicus.  She 
lived  for  four  and  one-half  years,  but  for  eight  months  prior  to  her  death  she  com- 
plained continually  of  pain  in  the  abdomen.  Brun  drew  attention  to  the  fact  that 
both  children  had  the  same  abnormal  congenital  formation. 

Umbilical  Polyp.  §  —  An  infant  boy,  born  at  term,  had  a  large  in- 
guinal hernia  and  an  umbilical  hernia  the  size  of  a  hazel-nut.  On  the  surface  of  the 
umbilical  hernia  was  a  small,  oval,  red,  engorged,  and  inflamed  nodule,  about  the 
size  of  an  olive-stone.  One  pole  was  free,  the  other  lay  in  the  umbilicus,  the  skin 
fold  of  which  formed  a  prepuce  for  it.  The  nodule  was  cut  off  with  scissors  and 
cauterized,  with  satisfactory  results.  Microscopic  examination  showed  that  the 
nodule  was  a  typical  adenoma.  These  authors  give  Kolaczek  credit  for  describing 
the  first  case  of  this  character. 

Umbilical  Polyp.  —  In  Colman's  1 1  case  the  polyp  was  the  size  of  a 
split-pea,  distinctly  pedunculated,  and  was  removed  from  just  within  the  dimple 
of  the  umbilicus  of  a  child  two  months  old.  It  was  first  noticed  when  the  child  was 
two  weeks  old. 

*  Booker:    Personal  communication. 

t  Broca,  A.:  Polype  de  l'ombilic.     Jour,  de  med.  et  de  chir.,  1904,  lxxv,  172. 

+  Brun,  L.  A. :  »Sur  une  espece  particuliere  de  tumeur  fistuleuse  stercorale  de  l'ombilic.  These 
de  Paris,  1834,  No.  238. 

§  Capette  et  Gauckler:  Note  sur  un  cas  d'adenome  ombilical.  Revue  d'orthopedie,  1903, 
xiv,  271. 

I  Colman,  W.  S. :  Adenomatous  Polypus  of  Umbilicus.  Trans.  Path.  Soc.  London,  1888, 
xxxix,  110. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  127 

Microscopic  examination  of  the  polyp  showed  that  it  was  composed  of  ordinary 
non-striated  muscle,  and  that  it  was  covered  with  a  thick  layer  of  mucous  mem- 
brane which  contained  Lieberkuhn's  follicles  and  adenoid  tissue,  being  exactly 
like  the  normal  mucous  membrane  of  the  small  intestine. 

An  Umbilical  Polyp  or  Enteroteratoma.  —  Diwawin* 
reports  the  case  of  a  male  child  who  had  a  pea-sized  tumor  situated  to  the  left  of 
the  center  of  the  umbilicus.  It  was  red  in  color  and  painless.  When  examined, 
it  was  the  size  of  a  cherry  and  was  freely  movable.  In  its  center  was  an  almost 
imperceptible  opening  into  which  a  small  sound  could  be  passed  for  2  mm.  The 
tumor  secreted  four  or  five  drops  of  bloody  mucus  in  the  course  of  a  day.  It  was 
removed  under  cocain.     The  growth  was  covered  with  intestinal  mucosa. 

Polypoid  Excrescences  at  the  Umbilicus  in  New- 
born  Infants.  —  Fabregef  reported  several  cases. 

Case  1  .  ■ —  In  a  small  boy,  one  month  old,  the  mother  noticed  a  moisture  at 
the  umbilicus  as  soon  as  the  cord  came  away.  At  the  umbilicus  was  a  reddish, 
pedunculated  tumor,  the  size  of  a  pea.  This  was  cut  away  with  scissors  and  the 
base  cauterized.  The  growth  apparently  returned.  It  was  treated  in  the  same 
manner,  and  the  wound  healed.  After  a  time,  however,  an  abscess  developed  at 
the  umbilicus.  This  was  opened,  and  there  escaped  with  the  pus  a  piece  of  wild- 
oat  straw  which  had  evidently  been  the  cause  of  the  abscess. 

Case  2  .  ■ —  A  baby  girl,  three  weeks  old,  was  found  to  have  a  tumor  the  size 
of  a  pea  lying  between  the  umbilical  folds.  The  polyp  was  red,  bled  readily  on 
being  touched,  and  had  a  definite  pedicle.  It  was  gradually  constricted  by  a  liga- 
ture and  dropped  off  on  the  third  day. 

In  neither  of  these  cases  was  there  any  microscopic  examination,  but  it  must  be 
remembered  that  these  patients  were  operated  upon  more  than  sixty  years  ago. 

An  Umbilical  Polyp. J  —  A  man,  twenty-four  years  of  age,  came 
to  the  hospital  on  July  17,  1893.  He  had  had  a  small  tumor  at  the  umbilicus  as 
long  as  he  could  remember.  It  had  never  become  any  larger.  It  secreted  a  thin, 
somewhat  sticky  mucus,  but  a  fecal  discharge  had  never  been  noted.  He  had 
had  no  pain,  but  there  was  a  certain  amount  of  discomfort  from  moisture. 

The  patient  had  always  suffered  from  constipation,  and  three  years  previously 
had  had  obstipation  for  three  days,  associated  with  great  abdominal  pain  and  with 
vomiting.  Five  days  before  admission  he  again  had  had  sudden  pain  in  the  abdo- 
men. He  had  had  no  stool,  but  had  vomited.  The  pain  had  continued,  but  the 
vomiting  had  ceased. 

The  abdomen  was  markedly  distended,  and  the  entire  umbilical  region  was 
moist.  The  skin  was  eczematous  in  appearance  and  was  peeling  off.  The  umbili- 
cus was  occupied  by  a  moist,  glistening,  scarlet-red  tumor  the  size  of  a  walnut. 
The  surrounding  skin  was  thickened  and  in  folds.  The  tumor  was  soft,  elastic, 
and  slightly  movable  on  its  pedicle. 

Operation. — The  abdomen  was  opened  and  the  bowel  found  drawn  up  and  ad- 
herent to  the  umbilicus  in  a  tent-like  manner.     On  being  loosened,  the  small  bowel 

*  Diwawin,  L.  A.:  Ein  Fall  von  Enteroteratom  des  Nabels.  Russ.  med.  Rundschau,  1904, 
ii,  590. 

t  Fabrege :  Note  sur  les  excroissances  polypeuses  de  la  fosse  ombilicale  chez  les  enfants  nou- 
veau-nes.     Revue  medico-chir.,  1848,  iv,  353. 

t  von  Gernet,  R.:  Ein  Enteroteratom.     Deutsche  Ztschr.  f.  Chir.,  1894,  xxxix,  467. 


128  THE    UMBILICUS    AND    ITS    DISEASES. 

tore  slightly.  The  wound  in  the  bowel  was  closed.  In  separating  the  tissues 
from  the  ligamentum  teres  the  operator  found  the  umbilical  vein  patent.  The 
abdomen  was  closed.  The  man  made  a  good  recovery.  The  tumor  was  2.5  cm. 
broad  and  2  cm.  long. 

On  microscopic  examination  the  outer  surface  of  the  tumor  was  found  to  be 
covered  with  mucosa.  The  glands  of  the  mucosa  were  tubular,  and  the  surround- 
ing tissue  showed  marked  inflammation.  The  gland  epithelium  was  cylindric.  Von 
Gernet  failed  to  find  goblet  cells,  but  the  glands  resembled  those  of  Lieberkiihn. 
In  the  center  of  the  tumor  were  delicate  bundles  of  non-striated  muscle.  Von 
Gernet  thought  the  case  one  of  enteroteratoma  due  to  prolapsus  of  the  mucosa  from 
remains  of  the  omphalomesenteric  duct. 

An  Umbilical  Polyp.  —  Giani*  reports  four  cases  of  enteroteratoma 
or  umbilical  polyp,  and  gives  excellent  illustrations.  These  cases  were  noted  in 
the  pediatric  clinic  of  Professor  Bajardi. 

A  Congenital  Mucous  Polyp  of  the  Umbilicus.  — 
Gould'sf  patient  was  a  male,  five  months  old.  He  had  a  bright-red,  soft,  peduncu- 
lated, smooth  growth,  about  the  size  of  a  large  currant,  springing  by  a  narrow  ped- 
icle from  the  umbilical  cicatrix.  At  the  upper  end  of  this  nodule  was  a  small  hole 
admitting  a  probe  for  one-eighth  of  an  inch.  The  tumor  was  moistened  with  thin 
mucus,  but  there  was  no  discharge  of  urine  or  feces.  This  small  nodule  was  first 
noticed  when  the  cord  fell  off.  It  was  then  nearly  the  same  size.  The  nodule  was 
ligated  and  cut  off.  Its  surface  was  covered  with  branching  glands  and  there  was 
the  typical  interglandular  substance.     It  was  covered  over  with  intestinal  mucosa. 

Intestinal  Occlusion  Caused  by  Persistence  of  the 
Omphalomesenteric  Duct.  Resection  of  the  Strangu- 
lated Intestine.  End-to-end  Anastomosis.  Recov- 
er y  .  t  —  A  man,  twenty-nine  years  of  age,  a  carter,  on  June  12th  had  colic  and 
had  to  go  to  bed.  Gradually  -signs  of  obstruction  developed.  Five  days  later 
he  was  seen  by  Hartmann.  At  that  time  he  had  fecal  vomiting  and  great  dis- 
tention. 

On  examination  there  was  seen  in  the  umbilical  depression  a  granular-like  nodule 
from  which  there  was  some  discharge.  A  probe  could  not  be  introduced.  No  his- 
tory as  to  the  appearance  of  this  nodule  could  be  obtained  from  the  patient. 

Operation. — When  the  abdomen  was  opened,  a  large  quantity  of  serous  fluid 
escaped.  The  small  bowel  was  dilated  and  injected.  The  point  of  obstruction 
was  located,  and  the  bowel  was  seen  to  be  divided  into  three  branches  of  equal 
volume.  All  three  branches  were  distended.  Remembering  the  appearance  of  the 
umbilicus,  Hartmann  at  once  thought  of  a  patent  omphalomesenteric  duct.  The 
abdominal  incision  was  now  extended,  and  the  omphalomesenteric  duct  and  the 
obstructed  loop  were  brought  out  and  removed.  The  bowel  was  brought  together 
with  an  end-to-end  suture  and  the  patient  recovered. 

The  diverticulum  was  noticeably  compressed  at  its  insertion  into  the  small  bowel. 
It  was  6  mm.  in  diameter  and  4  cm.  long.     It  was  continued  as  an  apparently  fibrous 

*  Giani,  R.:    Per  la  casistica  degli  entero-teratomi  dell'ombelico.     Clinica  moderna,  1902, 

viii,  4!*S. 

t  Oould,  A.  Pearce:  Trans.  Path.  Soc.  London,  1881,  xxxii,  204. 

+  Hitrtrnann:  Occlusion  intestinale  par  un  canal  omphalo-mesenterique  persistant.  Bull. 
el  Mem.  de  la  Hoc.  de  chir.  de  Paris,  1898,  n.  s.,  xxiv,  202. 


EEMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT. 


129 


Fir,.  70. — A  Polypoid  Outgrowth 
peom  the  Umbilicus.  (After  Hek- 
toen.) 

Histologic  examination  showed 
that  it  was  a  so-called  adenoma  of  the 
umbilicus;  in  other  words,  remains  of 
the  omphalomesenteric  duct.  For  the 
histologic  picture  see  Fig.  71. 


cord,  3.5  cm.  long  and  4  mm.  in  diameter,  which  terminated  in  the  granulation  noted 
at  the  umbilicus.     The  patient  made  a  good  recovery. 

Vitelline  Duct  Remains  at  the  Navel.*  —  "In  November, 
1892,  a  boy,  fifteen  years  old,  was  brought  to  me  by 

his  father  because  the  navel,  which  he  stated  had        ,,.-■■,.  ;  ' 

never  healed,  had  become  a  source  of  discomfort  to 
his  son,  especially  when  walking.  It  was  learned 
that  there  had  been  something  wrong  with  the  navel 
since  birth,  and  the  blame  for  this  was  placed  on  the 
midwife,  who  was  supposed  to  have  made  a  mistake 
in  cutting  the  cord.  There  had  been  no  special  in- 
convenience felt  until  very  recently,  when  it  was 
noticed  that  the  navel  became  tender  and  sore,  par- 
ticularly after  walking  or  running;  a  little  matter 
had  also  appeared,  staining  the  clothes.  It  was  no- 
ticed that  the  boy  walked  carefully,  bending  his  body 
forward.  The  previous  history  was  otherwise  nega- 
tive, and  the  father  had  no  knowledge  of  any  such  or 
similar  conditions  in  any  of  the  other  members  of  the 
family.  Physical  examination  showed  a  well-devel- 
oped boy,  in  good  general  health,  whose  body  was 
free  from  all  blemish  except  at  the  umbilicus,  which 
presented  the  following  appearance: 

"Projecting    from    its    lower  third  is   a   pedunculated,   polypoid   outgrowth 
(Fig.  70)   2.5  cm.  in  length  and  3  cm.  at  its  widest   circumference,   near  the 
rounded,   free  end.      This    mass    is    of    a  uniform,   deep-red    color,   its  surface 
delicately  smooth  and  velvety,  covered  with  grayish,  mucoid  shreds.     The  nar- 
row peduncle  is  apparently  attached  to  the  fibrous 
g     >    a  ;  ~  structures  in  the  floor  of   the   umbilical  depression, 

as  the  volume  cannot  be  diminished  the  slightest 
by  pressure  toward  the  abdominal  cavity.  In  other 
words,  this  red  mass  is  not  reducible.  There  is  no 
opening  found  upon  the  surface  nor  depression  that 
might  suggest  the  previous  existence  of  any  orifice 
or  canal.  The  line  of  junction  of  the  skin  with  the 
covering  of  the  peduncle  at  the  bottom  of  the  um- 
bilicus is  even  and  abrupt.  The  pedicle  crowds  up- 
ward the  folds  of  the  integument  covering  the  navel, 
and  it  is  somewhat  compressed  as  it  escapes  from 
the  grasp  between  these  folds  and  the  circumference 
of  the  umbilicus  below,  upon  which  are  small  but  ex- 
ceedingly sensitive  ulcers.  The  mass  itself  is  not 
sensitive  to  the  touch,  but  it  bleeds  readily,  bright 
red  blood  oozing  out  when  handled  a  little  roughly. 

"A  diagnosis  of  a  so-called  adenoma  or  diverticular  prolapse  at  the  umbilicus  was 
made,  a  ligature  was  placed  around  the  pedicle  near  its  attachment,  and  the  poly- 
poid outgrowth  was  cut  away  with  scissors.     No  hemorrhage  followed.     In  a  week 

*  Hektoen,  Ludvig:  Amer.  Jour.  Obst.,  1893,  xxviii,  340. 
10 


f 


Fig.  71. — Tubular  Glands  from 
the  Umbilical  Polyp  shown 
in  Fig.  70.     (After  Hektoen.) 
These  covered  the  outer  sur- 
face of  the  specimen.     The  growth 
was  evidently  a  so-called  adenoma 
of  the  umbilicus. 


130  THE    UMBILICUS    AND    ITS    DISEASES. 

the  ligature  fell  off,  and  in  a  few  weeks  afterward  the  little  red  spot  left  was  com- 
pletely cicatrized. 

"Immediately  after  its  removal  the  mass  was  divided  into  numerous  suitable 
pieces,  fixed  in  Flemming's  solution,  washed  in  water,  dehydrated  in  alcohol,  em- 
bedded in  paraffin,  and  microtomized.  The  sections  thus  obtained  were  stained  in 
various  fluids,  and  the  microscopic  appearances  may  be  summarily  described  as 
follows :  There  are  two  principal  layers  to  be  taken  into  account — a  peripheral  or 
glandular  zone,  and  an  internal  central  mass  consisting  of  smooth  muscular  fibers 
and  connective  tissue.  The  surface  is  lined  or  covered  with  tall,  symmetrically 
nucleated,  columnar  cells  without  any  demonstrable  cilia,  placed  upon  an  unbroken, 
quite  homogeneous  basement  membrane.  Projecting  from  this  surface  are  villous, 
club-shaped  masses  consisting  of  loosely  meshed  connective  tissue,  in  which  are 
many  nuclei  and  small  blood-vessels.  Between  these  rather  short,  club-shaped  villi 
are  the  openings  of  the  gland  tubules,  which  compose  the  glandular  zone  of  the  out- 
growth. The  tubules  are  lined  with  more  or  less  cuboid  epithelial  cells,  disposed 
in  a  single  layer,  with  a  tendency  to  assume  the  appearance  of  cylindric  cells  as  the 
free  surface  is  approached.  The  tubules  terminate  in  blind  extremities  which  are 
buried  in  the  intertubular  connective  tissue  deep  down  in  the  mass;  their  lumina 
are  empty;  the  cells  present  distinct  outlines,  a  granular  protoplasm,  and  deeply 
stained  nuclei.  In  many  of  the  cells,  both  of  those  lining  the  tubules  and  the  free 
surfaces,  are  seen  typical  karyokinetic  figures  in  the  sections  prepared  for  the 
purpose  of  bringing  them  into  prominence."  In  Fig.  71  is  presented  a  portion  of  the 
deeper  strata  of  the  glandular  zone  with  the  tubules  in  transverse  section.  In 
Hektoen's  next  figure  (which  we  have  omitted)  is  a  portion  of  the  periphery,  with 
a  villous  projection,  which  had  been  cut  in  a  direction  somewhat  oblique  with  refer- 
ence to  the  main  or  longitudinal  axis  of  the  outgrowth,  and  this  fact  will  explain 
the  presence  in  its  center  of  hollow  spaces  lined  with  tall  columnar  cells.  The  inter- 
tubular tissue  contains  quite  a  number  of  blood-vessels  of  medium  size,  the  majority 
containing  blood;  there  are  also  a  few  foci  of  round-cell  infiltration  here  and  there, 
suggesting  some  inflammatory  process. 

' '  Internally,  to  the  blind  extremities  of  the  tubules  and  the  accompanying  inter- 
tubular connective  tissue,  is  a  zone  of  smooth  muscular  tissue  whose  arrangement 
cannot  be  said  to  follow  any  definite  plan,  and  in  the  very  center  of  the  whole  mass 
is  a  quantity  of  rather  firm,  fibrillated  connective  tissue.  No  lymphatic  gland 
structure  was  found  in  any  part  of  the  sections  examined. 

"The  microscopic  structure  of  the  outgrowth  consequently  corresponds  very 
closely  with  the  structure  of  the  mucous  membrane  of  the  small  intestine,  with  its 
Lieberkiihn  follicles  or  the  characteristic  cylindric-cell  lining  of  its  exterior.  The 
structure  of  the  central  part  of  the  mass  also  reproduces  the  smooth  muscular  and 
the  connective  tissue  found  in  the  wall  of  the  small  intestine,  although  the  arrange- 
ment of  these  tissues  is  not  typical  of  that  in  the  intestine.  It  is,  therefore,  plain 
that  the  polypoid  umbilical  outgrowth  described  is  an  instance  of  the  so-called 
diverticular  prolapse  at  the  navel,  which  is  somewhat  unusual  from  the  fact  that, 
although  congenital,  it  was  first  brought  under  observation  fifteen  years  after  birth." 

On  page  344  Hektoen  gives  excellent  pictures  of  the  nuclear  division- 

A    Possible    Umbilical    Polyp.*  —  In  a  boy,  six  weeks  old,  the 

*  Henke:  Zur  Casuistik  der  vollkommenen  Nabel-Darm-Fisteln  durch  Persistenz  des  Ductus 
omphalo-entericus.     Deutsche  Zeitschr.  f.  prakt.  Med.,  1877,  iv,  486. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  131 

umbilical  groove  was  filled  with  a  fungus-like  growth,  1.5  cm.  in  diameter.  It 
had  a  glistening  red  color  and  was  covered  with  a  clear,  whitish,  sticky  secretion. 
There  was  a  slight  erythema  around  the  umbilicus.  Nothing  abnormal  had  been 
noted  in  the  cord  at  the  time  of  labor,  but  some  days  later  clear  fluid  had  escaped 
from  the  umbilicus  and  the  nodule  was  detected.  Astringents  were  used  and  it 
disappeared.  From  the  history  this  may  have  been  either  an  umbilical  polyp  or 
granulation  tissue. 

A  Probable  Umbilical  Polyp.*  —  The  boy  was  four  weeks  old. 
Springing  from  the  umbilicus  was  a  pear-shaped  tumor,  0.5  cm.  long,  and  divided 
into  three  lobes.  Where  the  third  lobe  joined  was  a  minute  opening,  from  which  a 
drop  of  white,  opalescent  fluid  could  be  squeezed.  Neither  the  pedicle  nor  the 
tumor  bore  any  resemblance  to  granulation  tissue.  They  were  covered  with  a 
bright-red  mucous  membrane.  The  nodules  were  noted  soon  after  the  cord  came 
away.     They  were  cauterized  and  disappeared. 

An  Umbilical  Polyp,  f  —  The  patient,  a  healthy  boy  three  years 
old,  had  had  a  small  umbilical  tumor  ever  since  the  cord  came  away.  This  had  bled 
severely  recently.  The  umbilicus  was  prominent.  In  the  umVjilical  groove  was  a 
pea-sized  tumor  with  a  dull-red  surface.  It  was  attached  by  a  short  pedicle  and 
was  covered  with  a  mucus-like  fluid.     It  was  removed. 

Microscopic  examination  showed  that  the  surface  was  covered  over  with  mucosa 
containing  Brunner's  and  Lieberktihn's  glands.  The  central  portion  consisted  of 
non-striped  muscle. 

Remains  of  the  Omphalomesenteric  Duct.  —  Holmes* 
says  that  warty  or  nipple-like  tumors  projecting  from  the  umbilicus  are  fairly  often 
seen  in  children,  and  that  they  seem  to  be  due  to  some  morbid  condition  left  by  the 
separation  of  the  umbilical  cord.  He  gives  Athol  Johnson  credit  for  the  first  refer- 
ence to  it  in  the  English  language.  Johnson  speaks  of  the  tumor  as  a  stout,  nipple- 
shaped  papilla  or  tubercle  arising  from  the  center  of  the  main  umbilical  depression. 

Holmes  says  that  these  may  attain  the  height  of  an  inch.  He  saw  several,  but 
none  as  large  as  this.     They  were  ligated. 

Umbilical  Tumor  in  an  Infant  Formed  by  Prolapse 
of  the  Intestinal  Mucous  Membrane  of  Meckel's  Di- 
verticulum. §  —  The  patient  was  seven  months  old.  A  bright-red  mass, 
34  of  an  inch  in  diameter,  projected  for  %  of  an  inch  from  the  bottom  of  the  um- 
bilical cicatrix.  This  projection  was  cylindric  and  slightly  rounded  at  its  extremity. 
It  was  pedunculated  at  its  cutaneous  attachment.  Its  surface  resembled  mucous 
membrane,  and  was  smooth  and  shiny.  At  one  point  where  the  epithelium  had 
been  rubbed  off  there  was  capillary  bleeding.  The  mass  was  solid,  did  not  protrude 
more  on  coughing  or  crying,  and  had  no  opening. 

In  this  case  the  cord  had  fallen  off  on  the  sixth  day  and  the  wound  did  not  heal 
completely  for  six  weeks.  On  one  occasion  there  was  hemorrhage  from  the  umbili- 
cus. The  tumor  was  discovered  six  weeks  after  birth  and  was  quite  small.  It 
steadily  increased  in  size  in  spite  of  the  use  of  astringents  and  caustics.     From  it 

*  Henke:  Loc.  cit. 

t  Hollaendersky,  Sara:  Zur  Kasuistik  der  Nabeltumoren.  Inaug.  Diss.,  Freiburg  i.  Br., 
1905. 

X  Holmes,  T.:  Surgical  Treatment  of  Children's  Diseases,  London,  1868,  181. 
§  Holt,  L.  E.:  Med.  Record,  1888,  xxxiii,  431. 


132 


THE    UMBILICUS    AND    ITS    DISEASES. 


Fig.  72.  —  Diverticular 
Tumor  at  the  Umbili- 
cus. (From  Hue's  Case 
1.) 

A  button-like  growth 
protrudes  from  the  umbili- 
cus, being  attached  by  a 
narrow  pedicle. 


there  was  a  slight  water}'  discharge,  but  no  fecal  masses  and  no  fecal  odor.     The 
tumor  was  ligated  and  cut  off. 

Its  outer  surface  was  covered  with  mucosa  similar  to  that  of  the  small  intestine. 
Here  and  there  it  was  slightly  necrotic. 

Holt  gives  two  good  pictures  of  the  condition.  He  holds  that  the  term  adenoma 
is  unfortunate,  misleading,  and  inexact.  He  credits  Kustner 
with  the  first  accurate  description  of  these  growths. 

Umbilical  Polyps.  —  Hue  *  refers  to  Villar's 
article,  published  in  1886,  and  to  that  of  Le  Blanc,  published 
in  1889.     He  then  reports  five  cases. 

Case  1  .  —  A  child,  four  years  old,  had  a  small  tumor 
at  the  umbilicus  which  had  been  noticed  eight  days  after 
birth,  as  soon  as  the  cord  came  away.  In  the  umbilical 
scar  was  a  pedunculated  tumor  the  size  of  a  cherry  (Fig. 
72).  The  pedicle  was  fibrous  and  hard.  The  tumor  was 
velvet}',  bright  red  in  color,  moist,  but  did  not  bleed,  and 
there  was  no  hernia.  An  elastic  ligature  was  applied  with 
good  results. 

Case   2  .  —  The  patient  was  four  and  one-half  months 
old.     After  the  cord  dropped  off,  a  tumor  the  size  of  a  pea 
was  noted  at  the  umbilicus.     It  was  red,  velvety,  and  had  a 
pedicle  3  mm.  long  (Fig.  73).     It  was  ligated  satisfactorily. 
Case   3  .  • —  A  child,  three  months  old,  had  a  tumor  the  size  of  a  pea  at  the 
umbilicus.     It  was  red  and  moist,  but  there  was  no  suppuration.     It  was  cut  off 
with  scissors  and  the  child  recovered  completely. 
C  a  s  e  4  presented  practically  the  same  picture. 

Case  5  .  —  The  child  was  two  years  old.     The  tumor  was  similar  in  size  and 
was  noted  when  the  cord  came  away.    It  was  excised.    Deve, 
who  made  the  microscopic  examination  (Fig.  74)  of  the  speci-  /  i 

men  for  Hue,  found  that  it  was  covered  with  intestinal  mu- 
cosa. The  surface  epithelium  was  cylindric.  There  were  no 
papillary  outgrowths.  The  glands  of  the  mucosa  varied 
considerably:  some  resembled  Lieberkuhn's  glands,  others 
those  of  the  pylorus,  and  still  others  those  of  Brunner.  Be- 
tween the  glands  were  lymph-follicles.  The  pedicle  was  made 
up  of  non-striped  muscle  and  fibrous  tissue.  The  mucosa 
joined  the  skin  of  the  abdomen. 

An  Umbilical  Pol  y  p  .  f — The  patient  was  three 
years  old.  The  mother  said  that  at  birth  nothing  unusual 
was  noted,  but  about  the  third  week  a  small  tumor  made 
its  appearance.  The  midwife  advised  the  wearing  of  a  band- 
age, and  this  had  been  done.  Despite  its  use,  however,  there 
had  been  a  good  deal  of  bleeding  from  the  tumor,  which  was 
about  as  large  as  a  cherry,  reddish,  and  consisted  of  three 

lobes  implanted  directly  in  the  umbilical  cicatrix.     It  looked  as  if  it  were  covered 
with  mucosa.     Its  surface  was  smooth  and  no  orifices  were  seen.     It  was  resistant 

*  Hue,  Francois:   Tumeurs  adenoides  diverticulaires.     La  Xormandie  med.,  1906,  xxi,  165. 
t  Kirmisson,  E.:  Ad&iome  diverticulaire  de  l'ombilic.     Revue  d'orthopedie,  1904,  xv,  47. 


Fig.  73. — A  Glandular 
Tumor  from  the  Um- 
bilicus. (From  Hue's 
Case  2.) 

Here  we  have  a  promi- 
nent projection  growing 
from  the  umbilicus.  The 
pedicle  is  rather  broad. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT. 


133 


and  irreducible.  Kirmisson  says  the  diagnosis  lay  between  granuloma  and  diver- 
ticular adenoma.  At  the  same  time  he  points  out  that  a  granuloma  is  softer  and 
appears  immediately  after  the  cord  comes  away.  This  tumor,  on  the  other  hand, 
was  not  noted  until  the  end  of  three  weeks;  it  was  firm  in  consistence,  and  was 
apparently  covered  with  mucosa.     It  was  excised  without  difficulty. 

Microscopically,  the  center  of  the  tumor  was  found  to  be  composed  of  connec- 
tive tissue  and  muscle;  its  outer  surface  was  covered  with  mucosa.  At  the  base 
of  the  pedicle  the  surface  for  a  distance  of  2  mm.  was  covered  with  squamous  epi- 
thelium.    The  mucosa  covering  the  tumor  was  of  the  type  found  in  the  small  in- 


f.  ci. 


gi.  k. 


pi.  m. 


Fig.  74. — A  Glandular  Growth  at  the  Umbilicus.  (From  Hue's  Case  5.) 
It  is  relatively  round,  and  has  grown  from  the  umbilicus.  Its  line  of  junction  with  the  skin  is  sharply  outlined. 
B,  The  submucosa;  C,  the  muscle;  D,  the  cellular  tissue.  In  the  center  of  this  is  a  nerve  ganglion,  gl  k.,  a  cystic 
Lieberkiihn  gland;  m.  m.,  muscularis  mucosae;  /.  cl.,  a  closed  follicle;  pi.  m.,  Auerbach's  plexus;  pyl.,  pyloric  glands; 
br.,  Brunner's  glands;  lieb.,  Lieberkiihn's  glands;  pav.,  the  squamous  epithelium.  The  line  of  junction  between  the 
squamous  epithelium  and  the  mucosa  is  sharply  outlined. 


testine.  In  Fig.  75  Kirmisson  gives  us  an  excellent  example  of  a  diverticular 
adenoma  of  the  umbilicus — an  umbilical  polyp. 

An  Umbilical  Polyp.  —  Kirmisson*  reports  the  case  of  a  child  eight 
days  old.  At  the  umbilicus  was  a  raised  tumor,  reddish  in  color,  irregular  in  form, 
smooth,  and  covered  with  a  shiny  mucus.  This  tumor  was  4  cm.  long  and  had  sev- 
eral purulent  pockets  on  its  surface.  It  presented  no  orifice  and  was  irreducible. 
Kirmisson  said  that  it  was  without  doubt  of  diverticular  origin.  Its  surface  was 
covered  with  mucosa  containing  glands. 

Umbilical  Polyps.  —  Case  1 . — In  1871  Kolaczekf  reported,  in  the  Jour- 

*  Kirmisson:  Les  tumeurs  de  l'ombilic.     Rev.  gen.  de  clin.  et  de  therap.,  Paris,  1907,  xxi,  726. 
t  Kolaczek:  ZweiEnteroteratomedesNabels.  Langenbeck's  Arch.  f.klin.Chir.,1875,xviii,  349. 


134 


THE    UMBILICUS    AND    ITS    DISEASES. 


nal  of  the  Pathological  Institute  of  Breslau  the  following  case :  A  boy  four  years 
of  age  had  a  small  umbilical  tumor.  The  hardened  specimen  showed  a  milky  outer 
surface  and  a  reddish  center.  On  microscopic  examination  its  surface  was  found  to 
be  covered  with  cylindric  epithelium,  and  opening  upon  the  surface  were  Lieber- 
kuhn's  glands.  Between  the  glands  were  lymphatic  tissue  and  connective  tissue. 
The  center  of  the  nodule  was  composed  of  smooth  muscle.  Kolaczek  thought  he 
was  dealing  with  an  enteroteratoma  of  the  umbilicus. 

Case    2  .  —  Kolaczek,  in  1874,  saw  a  boy  eighteen  months  old  who  had  a 
cylindric  tumor,  8  mm.  by  4.5  mm.  thick,  at  the  umbilicus.     The  growth  showed  a 


d  — 


/.... 


Fig.  75. — Section  in  the  Long  Axis  of  a  Small  Umbilical  Growth.     (After  Kirmisson.) 
a,  The  mucosa;    b,  glands  of  Lieberkiihn;    b',  indicates  the  superficial  portion  of  the  glands  which  can  be  traced 
through  their  entire  length;   c,  the  glands  in  their  depth;  c',  the  dichotomous  branching  noticed  in  their  depth;  d,  the 
muscular  fibers;  e,  the  vessels;  /,  squamous  epithelium;  g,  the  pedicle  of  the  tumor. 


small,  granulation-like  top.  It  was  noted  shortly  after  the  cord  came  away,  and 
was  removed  with  the  knife  with  satisfactory  results. 

Microscopically  the  picture  was  similar  to  that  noted  in  the  first  case.  There  is 
no  doubt  that  both  of  these  tumors  were  remains  of  the  omphalomesenteric  duct. 

An  Umbilical  Polyp.  —  Kiistner  *  says  that  about  a  year  before  he 
published  his  article  he  examined  a  fungus  which  had  been  removed  from  the  um- 
bilicus of  a  child  three  months  old.  He  did  not  expect  to  find  anything  but  granu- 
lation tissue,  and  was  not  a  little  surprised  to  find,  instead  of  this  simple  structure, 

*  Kiistner,  O.:  Notiz  uber  den  Bau  des  Fungus  umbilicalis.     Arch.  f.  Gyn.,  1876,  ix,  440. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  135 

a  relatively  complicated  picture.  In  the  center  was  connective  tissue,  and  outside 
of  this  were  round  cells  and  granulation  tissue.  Embedded  in  the  periphery  were 
numerous  tubular  glands.  The  tumor,  which  was  the  size  of  a  pea,  was  covered 
with  beautiful  cylindric  epithelium. 

Umbilical  Polyps.  —  Lannelongue  and  Fremont*  reported  three  cases. 

Case  1  .  —  The  child  was  four  months  old.  When  the  cord  came  away  on 
the  ninth  day  a  small  reddish  tumor  was  noted  at  the  umbilicus.  It  was  cauterized 
with  silver  nitrate  several  times,  but  continued  to  grow.  It  was  cuboid  in  form, 
red  in  color,  firm  and  irreducible,  and  measured  8  mm.  in  diameter.  It  was  cut  off. 
Lannelongue  and  Fremont  give  a  beautiful  plate  showing  an  outer  covering  of  in- 


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Fig.  76. — Adenoma  of  the  Umbilicus.     (After  Lannelongue  and  Fremont.) 
The  specimen  represents  a  transverse  section  through  a  so-called  adenoma  of  the  umbilicus.     The  central  stem  is 
made  up  of  non-striped  muscle-fibers  cut  transversely.     Surrounding  this  is  a  zone  of  the  fibrous  tissue,  and  the  outer 
surface  is  covered  with  a  mucosa  consisting  essentially  of  glands  of  the  small  intestine  (from  Case  1). 

testinal  mucosa,  and  beneath  a  submucosa.  The  center  was  composed  of  non- 
striped  muscle  (Fig.  76). 

Case  2  .  —  The  child  was  in  its  ninth  month.  At  labor  the  cord  looked  nor- 
mal, but  when  it  came  away  on  the  eighth  day  there  was  left  at  the  umbilicus  a 
small  tumor,  over  1  cm.  long  and  about  1  cm.  in  diameter.  Silver  nitrate  was  used 
several  times  without  success.  On  examination  the  tumor  was  found  to  be  solid, 
was  bright  red,  and  suggested  the  mucosa  of  a  prolapsed  rectum.  It  secreted  a 
serous  liquid.  On  one  side  was  a  slight  depression.  When  the  growth  was  cut  off, 
a  small  artery  spurted.  On  microscopic  examination  it  was  found  to  be  covered 
with  intestinal  mucosa;  the  center  was  composed  of  non-striped  muscle. 

Their  Plates  2  and  3,  illustrating  this  case,  are  excellent. 

*  Lannelongue  et  Fremont:  De  quelques  varietes  de  tumeurs  congenitales  de  l'ombilic  et 
plus  specialement  des  tumeurs  adenoides  diverticulaires.   Arch.  gen.  de  med.,  1884,  7e  ser.,  xiii,  36. 


136  THE    UMBILICUS    AND    ITS    DISEASES. 

Case  3  .  —  The  record  is  incomplete,  but  the  microscopic  findings  were  simi- 
lar to  those  of  the  other  cases. 

An  Umbilical  Polyp  Associated  with  a  Partially 
Patent  Omphalomesenteric  Duct.*  —  The  patient  was  a  boy. 
On  the  eleventh  day  the  cord  came  away  and  a  cylindric  tumor,  with  an  elevation 
the  size  of  one  phalanx,  was  found  at  the  umbilicus.  This  had  a  "wild-flesh"  ap- 
pearance, and  discharged  blood  and  pus.  It  was  removed  with  a  knife.  At  once 
a  loop  and  then  a  large  quantity  of  the  small  bowel  came  out  of  the  wound.  The 
omphalomesenteric  duct  near  the  bowel  was  patent,  the  lumen  measuring  6  mm.  in 
diameter.  The  opening  was  sutured,  and  the  abdomen  closed.  The  child  made  a 
good  recovery.  On  microscopic  examination  the  polypoid  tumor  was  found  cov- 
ered with  mucosa  containing  Lieberkuhn's  glands.  Its  central  portion  consisted 
of  non-striped  muscle. 

[In  this  case  there  was  a  patent  omphalomesenteric  duct,  open  at  its  inner  end, 
with  slight  obliteration  in  its  middle  portion;  and  in  addition  to  this  a  remnant  of 
the  duct  in  the  form  of  a  polyp  at  the  outer  end.] 

Congenital  Umbilical  P  o  1  y  p  .  f  — ■  The  boy  was  three  years  of 
age.  An  umbilical  tumor  had  been  noted  since  birth.  It  was  the  size  of  a  small 
bean,  and  was  bright  red  in  color,  soft  and  fleshy  to  the  touch,  perpetually  moist, 
and  tended  to  bleed  on  manipulation.    There  was  no  sinus.    It  had  a  narrow  pedicle. 

On  microscopic  examination  it  was  found  to  present  the  typical  appearance. 
It  was  covered  with  mucosa,  which  contained  glands  resembling  those  of  Lieberkuhn. 

An  Umbilical  Polyp.  —  In  Magnanini's  +  case  there  was  a  small 
tumor  at  the  umbilicus  from  which  there  was  persistent  hemorrhage.  It  was  diag- 
nosed as  an  adenoma.     It  belonged  to  the  class  of  cases  described  by  Ktistner. 

Umbilical  Polyp.  —  In  Morton's  §  case  the  child  was  seven  months 
old.  At  the  umbilicus  was  a  bright-red,  sessile  growth,  the  size  of  a  pea.  Silver 
nitrate  was  used  without  effect.     Later  the  growth  was  ligated  and  snipped  off. 

On  microscopic  examination  the  surface  epithelium  was  absent,  but  in  the  under- 
lying tissue  were  found  Lieberkuhn's  glands. 

Case  2  .  —  The  child  was  "  a  few  years  old."  At  the  umbilicus  was  a  red 
growth  the  size  of  a  pea.  It  had  a  smooth,  slightly  moist,  weeping  surface  and 
was  pedunculated.  Caustics  were  applied  with  but  little  effect.  On  microscopic 
examination  Lieberkuhn's  glands  were  found;  they  lay  in  the  center,  however, 
instead  of  on  the  periphery  of  the  tumor. 

Probably  an  Umbilical  Polyp.  —  Parker,  ]  |  in  his  report  of  cases  of 
excision  of  the  umbilicus  for  malignant  disease,  reports  the  findings  in  the  case  of  a 
boy  twenty-nine  months  old.  Soon  after  birth  the  parents  noticed  that  the  navel 
did  not  heal.  There  was  a  hard  mass  occupying  the  place  where  the  cord  joins  the 
abdominal  wall;  and  to  the  right  of  the  cord  a  naked,  non-cicatrized  surface,  discharg- 

*  Lowenstein:  Der  Darmprolaps  bei  Persistenz  des  Ductus  omphalomesentericus  mit  Mit- 
theilung  eines  operativgeheilten  Falles.     Langenbeck's  Arch.  f.  klin.  Chir.,  1894-95,  xlix,  541. 

!  M.i kins  and  Carpenter:  A  Case  of  Congenital  Umbilical  Polyp.  Illustrated  Med.  News, 
London,  1889,  ii,  268. 

\  Magnanini,  X.:  Tumor  diverticular  del  dmbligo.  Anales  del  circulo  medico  Argentino, 
L898,  xxi,  449. 

§  Morton,  Charles  A.:  The  Umbilical  Growths  of  Infants  and  Young  Children.  Pediatrics, 
1896,  ii,  409. 

||  Parker,  Willard:  Excision  of  Umbilicus  for  Malignant  Diseases.  Arch.  Clin.  Surg.,  New 
York,  1870-77,  i,  71. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  137 

ing  a  thin  sanious  fluid.  This  area  failed  to  cicatrize,  and  the  tumor  increased  in  size. 
When  the  boy  was  three  years  old,  an  attempt  was  made  to  remove  the  growth,  but 
only  part  was  taken  away,  as  it  was  found  to  extend  into  the  abdomen.  Fifteen 
months  later  the  tumor  was  harder  and  firmer  and  increasing  in  size.  An  elliptic 
piece  of  the  abdominal  wall,  including  the  tumor,  was  excised.  The  child  made  a  good 
recovery.  [Dr.  Alonzo  Clark,  who  made  the  microscopic  examination,  thought  that 
the  growth  was  cancerous.  It  was,  however,  in  all  probability  an  adenoma  of  the 
abdominal  wall.] 

Adenoma  of  the  Umbilicus.*  —  The  patient  was  a  boy  three 
months  old.  When  the  cord  came  away  the  mother  noticed  a  small  moist  nodule 
at  the  umbilicus.  It  was  the  size  of  a  pea,  red,  uniform,  and  covered  with  mucosa. 
It  had  no  opening  and  was  irreducible.  It  was  removed,  and  on  microscopic  exami- 
nation showed  an  outer  surface  of  intestinal  mucosa  with  non-striped  muscle  be- 
neath. It  was  a  typical  adenoma.  Phocas  then  gives  a  resume  of  the  literature 
on  the  subject. 

An  Umbilical  Polyp. —  Simpson  f  reported  a  case  which  he  saw  with 
Dr.  Findlay.  The  excrescence  was  the  size  of  a  cherry,  which  it  likewise  resembled 
in  color.  It  was  apparently  insensible  to  touch,  but  blood  oozed  from  its  red  surface 
on  slight  handling.  Silver  nitrate  was  applied  to  it  several  times  with  no  effect. 
After  several  weeks  a  ligature  was  passed  around  its  base,  and  in  a  few  days  it 
dropped  off. 

An  Umbilical  Polyp.f —  A  boy  twenty-one  months  old  was  admitted 
to  Maas's  clinic.  After  the  cord  came  away  a  prominence,  1.5  cm.  high  and  5  mm. 
thick,  was  noted  at  the  umbilicus.  The  tumor  was  reddish  and  suggested  a  red 
granulation,  but  the  color  was  brighter.  It  was  pedunculated  and  was  noted  when 
the  cord  came  away.  It  had  a  slightly  nodular  surface  and  was  rounded  on  the 
end.  It  was  moist  and  secreted  an  alkaline  fluid.  There  was  no  central  lumen. 
It  was  removed  with  the  cautery. 

On  microscopic  examination  it  was  found  to  be  covered  with  mucosa  containing 
Lieberkiihn's  glands.  The  surface  epithelium  had  evidently  been  rubbed  off.  The 
center  was  composed  of  bundles  of  smooth  muscle.  It  was  a  remnant  of  the 
omphalomesenteric  duct. 

An  Umbilical  Polyp.  §  —  The  patient  was  twenty  years  old.  At 
the  umbilicus  moisture  and  a  reddish,  cupped  tumor  the  size  of  a  cherry  were  de- 
tected. Its  surface  was  irregular  and  lobulated,  and  it  was  covered  with  a  viscid 
secretion.     It  was  removed. 

Microscopically  it  resembled  an  adenoma,  but  Stori  considered  it  a  papillo- 
adenoma  originating  at  the  umbilicus  from  remains  of  the  omphalomesenteric  duct. 

An  Umbilical  Polyp.  —  Tikhoff , 1 1  in  his  Fig.  44,  shows  a  polypoid 
projection  from  the  umbilicus,  and  in  Fig.  46,  accompanying  his  article,  the  typical 
picture  of  an  adenoma  covered  over  with  intestinal  glands.  The  description  of  this 
case  is  in  Russian. 

*  Phocas:  Adenomes  de  l'ombilic.     Nord  medical,  1S98,  iv,  52. 

t  Simpson,  J.  Y.:  Obstetric  Memoirs  and  Contributions,  Philadelphia,  1856,  ii,  423. 

X  Steenken,  C:  Zur  Casuistik  der  angebornen  Nabelgeschwiilste.  Inaug.  Diss.,  Wurzburg, 
1886. 

§  Stori,  Teodoro :  Contribute  alio  studio  dei  tumori  dell'ombehco.  Lo  Sperimentale  Archivio 
di  biologia  normale  e  patologia,  1900,  liv,  25. 

||  Tikhoff,  P.:   Khirurg.  lyetop.,  Mosk.,  1893,  iii,  581. 


138 


THE    UMBILICUS    AND    ITS    DISEASES. 


Fig.  77. — Ax  Umbilical  Polyp  At- 
tached to  Meckel's  Diverticu- 
lum bt  a  Fibrous  Cord.  (After 
Walther.) 

A,  Meckel's  diverticulum;  B,  ade- 
noma of  the  umbilicus;  C,  the  fibrous 
cord;  D,  the  skin;  E,  aponeurosis;  F, 
a  serous  band  uniting  the  loop  of  small 
bowel  from  which  the  fistula  springs 
with  another  loop  of  small  bowel. 


An    Umbilical    Polyp.  — ■  Villar *  reports  the  case  of  an  infant,  four 
months  old,  who  was  admitted  to  the  service  of  Nicaise  in  December,  1885.     The 

report  was  communicated  to  him  by  Le  Roy.  Since 
birth  this  child  had  presented  at  the  umbilicus  a 
small,  reddish  elevation  which  had  never  changed 
much  in  volume.  Nothing  unusual  was  detected  in 
the  cord,  but  the  mother  noticed  this  little  mass  just 
as  soon  as  the  cord  came  away.  The  child  had  never 
had  any  intestinal  trouble.  At  the  umbilical  cicatrix 
was  a  tumor  the  size  of  a  small  pea.  It  was  spheric, 
and  attached  to  the  umbilical  depression  by  an  ex- 
tremely short  pedicle.  It  was  dark  red,  smooth,  and 
irreducible.     It  was  removed. 

Microscopic  sections  showed  that  the  surface 
was  covered  with  cylindric  epithelium,  beneath 
which  were  tubular  glands  similar  to  those  of  the 
small  intestine. 

Umbilical  Polyps.  —  Virchow f  refers 
to  the  umbilical  fungus.  He  says  there  are  two 
kinds  of  tumor:  (1)  The  one  more  commonly  met 
with  is  rich  in  blood-vessels  and  bleeds  easily;  it  is 
found  immediately  after  the  cord  comes  away.  It 
represents  a  case  of  granulation,  and  after  the  use 
of  astringents  soon  disappears.  (2)  A  congenital 
tumor.  He  refers  to  two  of  these  cases,  reported 
by  Maunoir  and  Lawton. 

An  Umbilical  Polyp  Associ- 
ated with  Meckel's  Diverticu- 
lum, which  was  Attached  to  the 
Umbilicus  by  a  Fibrous  Cord.  J  — 
A  youth,  eighteen  years  old,  had  a  tumor  at 
the  umbilicus  the  size  of  a  large  cherry.  It  was 
about  2.5  cm.  long  and  2  cm.  broad,  was  red, 
velvety,  moist,  and  resembled  intestinal  mucosa. 
It  was  connected  with  the  umbilicus  by  a  pedi- 
cle. It  secreted  a  serous  fluid  which  became 
slightly  purulent  on  account  of  irritation  from 
the  clothes.  The  skin  in  the  vicinity  was  red 
and  erythematous.  There  was  no  trace  of  an 
umbilical  hernia.  The  boy  had  had  this  tumor 
since  birth.     It  had  grown  ver\-  little. 

An  elliptic  incision  was  made  around  the  um- 
bilicus, and  it  was  found  that  this  polyp  was  connected  with  Meckel's  diverticulum 
by  a  solid  fibrous  cord  (Figs.  77  and  78).     Recovery  took  place. 

*  Villar,  Francis:  Tumeurs  de  TombiUc.     These  de  Paris,  1886,  No.  19,  obs.  28. 
t  Virchow,  R.:  Die  krankhaften  Geschwiilste,  1862-63,  iii,  erste  Halfte,  467. 
i  Walther,  C. :  Tumeur  adeno'ide  de  l'ombilic  et  diverticule  de  Meckel.     Revue  d'orthopedie, 
1904,  xv,  23. 


Fig.  78. — Ax  Umbilical  Polyp  Attached 
to    Meckel's    Diverticulum    by    a 
Fibrous  Cord.     (After  Walther.) 
A,  Meckel's  diverticulum;     B,  adeno- 
ma of  the  umbilicus;   C,  fibrous  cord.     The 
transverse    dark    area    indicates    the    ab- 
dominal wall. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT. 


139 


Fig.  79. — Umbilical  Polyp. 
Gyn.-Path.  No.  16866.  (Specimen  sent  by  Dr.  E.  W.  Meredith,  of  Pittsburgh.  The  patient  was  a  young  adult.) 
The  upper  picture  shows  the  umbilicus  with  the  smooth  nodule  springing  from  the  umbilical  depression.  This  nodule 
was  covered  with  intestinal  mucosa.  The  lower  picture  is  twice  the  natural  size,  and  shows  the  relation  of  the  polyp 
to  the  umbilicus  on  cross-section.  The  mucous  surface  of  the  polyp  merges  directly  with  the  skin  surface  of  the  um- 
bilical depression.  The  center  of  the  polyp  consisted  of  non-striped  muscle.  For  the  low  and  high  power  pictures  of 
the  polyp  see  Figs.  80,  81,  and  82. 


Fig.  80. — A  Small  Intestinal  Polyp  Almost  Filling  the  Umbilical  Depression.     (X  5  diam.) 
The  section  is  through  Fig.  79.     The  squamous  epithelium  covering  the  umbilical  depression  is  clearly  visible  ,and 
beneath  it  one  finds  the  rarefied  stroma.     The  polyp  is  covered  over  with  intestinal  mucosa,  which  in  the  specimen  is 
rather  hazy.     The  dark  areas  in  the  polyp  are  aggregations  of  small  round  cells  or  lymph  cells.     For  the  higher  power 
picture  see  Fig.  S2. 


140 


THE    UMBILICUS    AND    ITS    DISEASES. 


Microscopic  Examination. — The  umbilical  nodule  was  surrounded  by  inflamed 
skin.  The  nodule  was  covered  with  intestinal  mucosa.  The  surface  was  necrotic. 
A  cord  consisting  of  fibrous  tissue  connected  the  polyp  with  Meckel's  diverticulum. 

A  Personal  Observation. 

An  Umbilical  Polyp  in  an  Adult. — On  October  7,  1911,  I 
received  the  following  from  Dr.  E.  W.  Meredith,  from  St.  Margaret's  Memorial 
Hospital,  Pittsburgh,  Pa.: 

"I  am  forwarding  to  you  a  specimen  of  an  'Umbilical  Tumor.'  The  patient 
is  a  healthy  young  man,  twenty  years  of  age.  The  tumor  had  been  present  since 
birth,  was  brilliant  red  in  color,  and  secreted  a  clear  mucoid  fluid. 


x6 


<r% 


>> 


i  I 


S  K 


i  v 


Fig.  81. — An  Umbilical  Polyp. 
Gyn.-Path.  No.  16866.  The  photomicrograph  (Fig.  80)  gives  the  general  relation  of  the  polyp,  but  naturally  lacks 
somewhat  in  detail.  Mr.  Brodel  has  given  us  a  very  clear  drawing  of  the  low-power  findings.  The  polyp  is  covered 
with  typical  intestinal  mucosa.  The  confines  of  the  pedicle  are  indicated  by  X.  It  consisted  in  a  large  measure  of 
non-striped  muscle.  The  mucosa  covering  the  polyp  ends  abruptly  where  the  squamous  epithelium  of  the  umbilical 
depression  begins.  The  squamous  epithelium  at  some  points  is  much  thickened.  Here  the  papilla;  are  elongated. 
The  area  indicated  by  the  circle  has  been  enlarged  and  is  shown  in  Fig.  82. 


"It  was  largely  on  account  of  the  constant  moisture  about  the  umbilicus  that 
the  patient  sought  operative  relief.  At  the  operation  the  umbilicus  with  its  central 
tumor  was  removed,  and  a  small  opening  made  into  the  peritoneal  cavity  to  explore 
the  under  surface  of  the  umbilicus.  This  was  found  to  be  smooth  and  free  of  any 
adhesions.  I  have  made  a  provisional  diagnosis  of  an  adenoma  of  omphalomesen- 
teric duct  origin." 

Gyn.-Path.  No.  16866.  —  The  specimen  consists  of  the  umbilicus 
and  of  a  small  amount  of  the  surrounding  tissue.  The  umbilical  opening  is  spheric, 
has  a  slightly  undulating  surface,  and  is  about  1.3  mm.  in  diameter.  Occupying 
the  greater  portion  of  the  umbilical  depression  is  a  rounded  polypoid  growth. 
This  has  a  smooth  surface,  is  translucent,  and  reminds  one  in  the  hardened  state  of 
a  section  through  intestinal  mucosa  (Fig.  79).     The  umbilicus  was  cut  in  two,  and 


REMNANTS  OF  THE  OMPHALOMESENTERIC  DUCT. 


141 


it  was  found  that  this  tumor  sprang  from  the  umbilical  depression  and  had  a  fairly 
broad  base  (Fig.  80).  Its  surface  was  directly  continuous  with  the  skin  surface  of 
the  umbilical  depression. 

Histologic  Examination.  —  Numerous  sections  were  made  through 
the  umbilicus  and  the  growth.  The  skin  covering  the  umbilicus  in  the  outer  por- 
tion of  the  section  is  perfectly  normal  (Figs.  81  and  82).  As  one  approaches  the 
umbilical  polyp  the  squamous  epithelium  becomes  somewhat  thinner,  but  pro- 


■:\ 


S 


xl6 


Fig.  82. — Portion  of  an  Intestinal  Polyp  Partially  Filling  the  Umbilical  Depression.     (X  16  diam.) 
In  the  upper  part  of  the  picture  is  seen  the  squamous  epithelium,  which  is  practically  normal.     The  stroma  be- 
neath it  shows  much  rarefaction.     The  squamous  epithelium  ends  abruptly  at  the  margin  of  the  polyp,  which  consists 
of  intestinal  mucosa.     The  surface  of  the  polyp  consists  almost  entirely  of  granulation  tissue  due  to  irritation  from  the 
clothing. 


longations  of  the  epithelium  are  continued  for  a  considerable  distance  into  the 
depth.  The  squamous  epithelium  ends  abruptly  where  the  polyp  begins.  The 
stroma  beneath  the  squamous  epithelium  near  the  umbilicus  is  normal,  but  nearer 
the  umbilical  depression  there  is  a  marked  change;  the  stroma  immediately  be- 
neath the  squamous  epithelium  becomes  rarefied,  takes  the  bluish  stain  instead  of 
the  pink,  and  reminds  one  very  much  of  myxomatous  tissue.  Scattered  throughout 
it  are  a  moderate  number  of  small  round  cells. 


142  THE    UMBILICUS   AND    ITS    DISEASES. 

The  polyp  filling  the  umbilical  depression  is  covered  over  with  intestinal  mucosa. 
Where  the  squamous  epithelium  ends,  the  mucosa  commences,  or  the  squamous 
epithelium  in  some  places  slightly  overlaps  the  intestinal  mucosa.  The  mucosa 
resembles  in  almost  every  particular  that  of  the  small  intestine.  In  the  more  promi- 
nent portions  of  the  polyp,  however,  the  surface  epithelium  has  disappeared  and 
fibrin  covers  the  surface.  The  tissue  immediately  beneath  shows  many  dilated 
capillaries;  there  is  much  small-round-cell  infiltration  and  a  moderate  number  of 
polymorphonuclear  leukocytes.  The  intestinal  glands  are,  however,  seen  opening 
directly  on  the  surface,  and  the  inflammatory  reaction,  without  doubt,  has  been 
caused  by  exposure  of  the  polyp  to  irritation  from  the  clothing.  The  stroma  form- 
ing the  central  portion  of  the  polyp  consists  in  large  measure  of  smooth  muscle- 
fibers.  Here  and  there  in  the  muscle,  and  also  directly  beneath  the  mucosa,  are 
clumps  of  small  round  cells. 

We  have  here  a  definite  intestinal  polyp  originating  from  a  remnant  of  the  outer 
portion  of  the  omphalomesenteric  duct.  The  low-power  picture  of  the  entire 
umbilical  growth  is  seen  in  Fig.  81.  With  the  higher  magnification  the  line  of 
junction  between  the  squamous  epithelium  of  the  umbilical  depression  and  the 
intestinal  mucosa  is  clearly  seen  in  Fig.  82.  Here  also  the  rarefied  condition  of  the 
stroma  beneath  the  squamous  epithelium  is  clearly  visible. 


LITERATURE  CONSULTED  ON  UMBILICAL  POLYPS. 
Ball,  C.  B.:  Case  of  Umbilical  Polyp.     Illustrated  Med.  News,  1889,  iv,  149. 
Bidone,  E. :  Enteroteratoma  ombelicale.     Bull,  delle  scienze  med.,  Bologna,  1901,  ser.  8,  i,  374. 
Blanc  et  Weil:  Soc.  anat.  de  Paris,  1899.     Rev.  in  Centralbl.  f.  allg.  Path.  u.  path.  Anat.,  1900, 

xi,  748. 
Blanc,  H. :  Contribution  a  la  pathologie  du  diverticule  de  Meckel.     These  de  Paris,  1899,  No.  393. 
Booker,  W.  D. :  Personal  communication. 

Broca,  A. :  Polype  de  l'ombilic.     Jour,  de  med.  et  de  chir.,  1904,  lxxv,  172. 
Brun,  L.  A. :   Sur  une  espece  particuliere  de  tumeur  fistuleuse  stercorale  de  l'ombihc.     These  de 

Paris,  1834,  No.  238. 
Capette  et  Gauckler:  Note  sur  un  cas  d'adenome  ombilical.     Revue  d'orthopedie,  1903,  xiv,  271. 
Colman,  W.  S.:   Adenomatous  Polypus  of  Umbilicus.     Trans.  Path.  Soc.  London,  1888,  xxxix, 

110. 
Diwawin,  L.  A.:  Ein  Fall  von  Enteroteratom  des  Nabels.     Russ.  med.  Rundschau,  1904,  ii,  590. 
Fabrege :  Note  sur  les  excroissances  polypeuses  de  la  fosse  ombilicale  chez  les  enf ants  nouveau- 

nes.     Revue  medico-chir.,  1848,  iv,  353. 
Fox  and  MacLeod :   Remains  of  the  Omphalomesenteric  Duct  at  the  Umbilicus  Giving  Rise  to 

Paget's  Disease.     Brit.  Jour.  Dermatol.,  1904,  xvi,  41. 
von  Gernet,  R. :  Ein  Entero-teratom.     Deutsche  Zeitschr.  f .  Chir.,  1894,  xxxix,  467. 
Giani,  R. :  Per  la  casistica  degli  entero-teratomi  dell'ombelico.     Clinica  Moderna,  1902,  viii,  498. 
Gould,  A.  P.:  A  Congenital  Mucous  Polypus  of  the  Umbilicus.     Trans.  Path.  Soc.  London,  1881, 

xxxii,  204. 
Hartmann:  Occlusion  intestinale  par  un  canal  omphalo-mesenterique  persistant.     Bull,  et  Mem. 

de  la  Soc.  de  chir.  de  Paris,  1898,  n.  s.,  xxiv,  203. 
Hektoen,  L.:  Vitelline  Duct  Remains  at  the  Navel.     Amer.  Jour.  Obst.,  1893,  xxviii,  340. 
Henke:    Zur  Casuist ik   der  vollkommenen  Nabel-Darm-Fisteln  durch  Persistenz  des  Ductus 

omphalo-entericus.     Deutsche  Zeitschr.  f.  prakt.  Med.,  1877,  iv,  486. 
Hollaendersky,  Sara:  Zur  Kasuistik  der  Nabeltumoren.     Inaug.  Diss.,  Freiburg  i.  Br.,  1905. 
Holmes,  T.:  Surgical  Treatment  of  Children's  Diseases,  London,  1868,  181. 

Holt,  L.  E.:  Umbilical  Tumor  in  an  Infant  Formed  by  Prolapse  of  the  Intestinal  Mucous  Mem- 
brane of  Meckel's  Diverticulum.     Med.  Record,  1888,  xxxiii,  431. 
Hue,  Francois:  Tumcurs  adenoides  diverticulaires.     La  Normandie  medicale,  1906,  xxi,  165. 


REMNANTS    OF    THE    OMPHALOMESENTERIC    DUCT.  143 

Kirmisaon,  E. :  Adenome  diverticulaire  de  l'ombilic.     Revue  d'orthopedie,  1904,  xv,  47. 
Kirmisson:  Les  tumeurs  de  l'ombilic.     Rev.  gen.  de  clin.  et  de  therap.,  Paris,  1907,  xxi,  726. 
Kolaczek:  Zwei  Enteroteratome  des  Nabels.     Langenbeck's  Arch.  f.  klin.  Chir.,  1875,  xviii,  349. 
Kiistner,  O.:    Notiz  liber  den  Bau  des  Fungus  umbilicalis.     Arch.  f.  Gyn.    1876,  ix,  440;    also 

Virchows  Arch.,  lxix,  286. 
Lannelongue  et  Fremont:    De  quelques  variety  de  tumeurs  congenitales  de  l'ombilic  et  plus 

specialement  des  tumeurs  ad^noides  diverticulaires.     Arch.  gen.  de  med.,  1884,  17.  ser.,  13,  36. 
Lowenstein:  Der  Darmprolaps  bei  Persistenz  des  Ductus  omphalomesentericus,  mit  Mittheilung 

eines  operativ  geheilten  Falles.     Langenbeck's  Arch.  f.  klin.  Chir.,  1894-95,  xlix,  541. 
Makins  and  Carpenter:   A  Case  of  Congenital  Umbilical  Polyp.     Illustrated  Med.  News,  Lon- 
don, 1889,  ii,  268. 
Magnanini,  N. :  Tumor  diverticular  del  Ombligo.     Anales  del  circulo  medico  Argentino,  1898,  xxi, 

449. 
Morton,  Charles  A. :   The  Umbilical  Growth  of  Infants  and  Young  Children.     Pediatrics,  1896, 

ii,  409. 
Parker,  Willard:   Excision  of  Umbilicus  for  Malignant  Diseases.     Arch.  Clin.  Surg.,  New  York, 

1876-77,  i,  71. 
Pernice,  L. :  Die  Nabelgeschwiilste,  Halle,  1892. 
Phocas:  Adenomes  de  l'ombilic.     Nord  medical,  1898,  iv,  52. 
Sheen,  W. :  Some  Surgical  Aspects  of  Meckel's  Diverticulum.     Bristol  Medico-Chir.  Jour.,  1901, 

xix,  312. 
Simpson,  J.  Y.:  Obstetric  Memoirs  and  Contributions,  Philadelphia,  1856,  ii,  423. 
Steenken,  C:   Zur  Casuistik  der  angebornen  Nabelgeschwiilste.     Inaug.  Diss.,  Wiirzburg,  1886. 
Stori,  Teodoro:    Contributo  alio  studio  dei  tumori  dell'ombelico.     Lo  Sperimentale  Archivio  di 

biologia  normale  e  patologia,  1900,  liv,  25. 
Tikhoff,  P. :    Case  of  anomalous  prolapse  of  omphalomesenteric  duct.     Khirurg.  lyetop.,  Mo6k., 

1893,  hi,  581-594.     1  pi. 
Villar,  Francis:  Tumeurs  de  1'ombihc.     These  de  Paris,  1886,  No.  19. 
Virchow,  R.:  Die  krankhaften  Geschwulste,  1862-63,  iii,  erste  Halfte,  467. 
Walther,  C. :  Tumeur  adeno'ide  de  l'ombilic  et  diverticule  de  Meckel.     Revue  d'orthopedie,  1904, 

xv,  23. 


CHAPTER  VII. 

CONGENITAL  POLYPS;  FISTULA  OR  CYSTIC  DILATATIONS  AT  THE 
UMBILICUS;  WITH  A  MUCOSA  MORE  OR  LESS  SIMILAR  TO  THAT 
OF  THE  PYLORIC  REGION  OF  THE  STOMACH,  AND  SECRETING 
AN  IRRITATING  FLUID  BEARING  A  MARKED  RESEMBLANCE  TO 
GASTRIC  JUICE.  PERSISTENCE  OF  THE  OUTER  PORTION  OF  THE 
OMPHALOMESENTERIC  DUCT. 

So-called  gastric  mucosa  at  the  umbilicus. 

General  consideration. 

Macroscopic  appearance. 

[Microscopic  picture. 

The  fluid  secreted  by  the  polyp  or  fistula. 

Action  of  the  fluid  on  the  skin  surrounding  the  umbilicus. 

Symptomatology. 

Origin. 

Treatment. 

Report  of  cases  of  congenital  polj'p  or  fistula  at  the  umbilicus  and  having  a  mucosa 
resembling  that  of  the  stomach. 
Persistence  of  the  outer  portion  of  the  omphalomesenteric  duct. 

Report  of  cases  in  which  the  outer  end  of  the  omphalomesenteric  duct  remained  patent. 

Tillmanns,  in  1882,  made  a  most  interesting  observation  .on  a  boy  thirteen 
years  old.  On  questioning  the  parents  it  was  learned  that  the  umbilical  cord  was 
unusually  thick,  and  that  it  had  dropped  off  on  the  fourth  day,  leaving  a  tumor  the 
size  of  a  cherry.  This  grew  slowly.  When  Tillmanns  saw  it,  it  was  the  size  of  a 
walnut,  bright  red  in  color,  and  covered  with  mucosa  (Fig.  87).  It  had  no  central 
opening.  It  was  attached  to  the  umbilical  depression  by  a  thin  pedicle.  After 
the  boy  had  eaten,  the  tumor  would  sometimes  swell  perceptibly;  it  would  become 
redder,  and  its  mucosa  thicker. 

This  umbilical  tumor  secreted  a  tenacious  mucus,  which  was  especially  abundant 
when  the  tumor  was  irritated.  At  such  times  2  to  3  c.c.  of  fluid  could  be  collected 
in  fifteen  minutes.  The  discharge  was  so  copious  that  it  was  necessary  to  wear 
dressings,  and  even  then  it  would  at  times  saturate  the  boy's  clothes. 

The  fluid  secreted  was  acid,  but  when  old,  it  became  alkaline.  The  fluid 
digested  fibrin  in  an  acid  solution  at  39°  C.  A  chemical  examination,  made  by  Dre- 
schel,  showed  that  it  corresponded  more  or  less  closely  with  gastric  juice. 

Microscopic  examination  of  the  tumor  revealed  the  fact  that  the  mucosa  was 
similar  to  that  of  the  stomach. 

The  digestive  action  of  the  fluid  secreted  by  this  tumor  had  caused  a  maceration 
of  the  abdominal  skin  surrounding  the  umbilicus.  The  pedicle  of  the  tumor  was 
severed,  and  the  wound  soon  healed  (Fig.  88).  No  connection  with  the  abdominal 
cavity  was  found. 

The  literature  on  this  subject  is  rather  scanty,  but  several  subsequent  observers 
have  reported  mucosa  at  the  umbilicus  that  bore  more  or  less  resemblance  to  stomach 
mucosa.     Cases  have  been  recorded  by  Roser  (1887),  Siegenbeek  van  Heukelom 

144 


SO-CALLED    GASTRIC    MUCOSA    AT    THE    UMBILICUS.  145 

(1888),  von   Rosthorn    (1889),   Reichard   (1898),  Weber    (1898),    Lexer    (1899), 
Strada  (1903),  Minelli  (1905),  and  Denuce  (1908). 

MACROSCOPIC  APPEARANCE  OF  THE  UMBILICAL  REGION. 
In  the  majority  of  the  cases  the  umbilical  abnormality  was  observed  just  as  soon 
as  the  cord  had  dropped  off.     The  local  picture  varies  considerably.     It  may  be 
roughly  classified  as  follows: 

1.  An  umbilical  polyp  attached  to  the  umbilical  depression  by  a  short  pedicle. 

2.  An  umbilical  polyp  with  a  cystic  cavity  opening  on  the  surface  of  the  polyp. 

3.  An  umbilical  fistula  with  or  without  a  small  projection. 

The  umbilical  polyp  in  van  Heukelom's  case,  and  also  in  Reichard's  case,  was 
the  size  of  a  hazel-nut;  and  in  Minelli's,  Strada's,  and  Tillmanns'  cases  the  tumor 
was  considerably  larger. 

Roser's  patient,  a  boy  a  year  and  a  half  old,  had  a  bright-red  swelling  at  the 
umbilicus,  and  opening  on  the  surface  of  it  was  a  cystic  cavity  1  cm.  in  diameter. 

In  Denuce's,  Lexer's,  von  Rosthorn's,  and  Weber's  cases  there  was  seen  at  the  um- 
bilicus a  fistulous  tract  which  extended  directly  inward  for  a  distance  of  1.5  to  2  cm. 

In  Lexer's  case  no  nodule  was  found  at  the  umbilicus,  but  in  the  other  cases  the 
cutaneous  end  of  the  fistula  had  raised  margins,  producing  a  small  red  thickening. 

Where  a  polyp  exists,  it  is  bright  red  in  color,  covered  with  mucosa,  and  is 
attached  to  the  umbilical  depression  by  a  definite  pedicle.  In  those  cases  in  which  a 
fistula  exists,  and  where  it  is  wide  enough  to  allow  one  to  see  its  inner  surface,  it  is 
found  lined  with  mucosa. 

THE  MICROSCOPIC  PICTURE. 

The  surface  of  the  polyp  is  covered  with  mucosa,  the  glands  of  which  resemble 
more  or  less  closely  those  found  at  the  pyloric  end  of  the  stomach.  In  certain  cases, 
some  of  the  glands  look  more  or  less  atrophic.  At  times  both  Lieberkuhn's  glands 
and  also  pyloric  glands  have  been  noted  in  the  mucosa. 

The  central  portion  of  these  polyps  consists  of  non-striped  muscle,  and  occasion- 
ally a  little  adipose  tissue  is  present. 

The  fistulse  are  lined  with  mucosa,  which  is  for  the  most  part  similar  to  that  of 
the  pyloric  region,  but  here  also  the  mucosa  at  one  point  may  contain  Lieberkuhn's 
glands,  and  at  another,  pyloric  glands.  This  was  particularly  well  shown  in 
von  Rosthorn's  case.  The  outer  walls  of  the  fistulous  tract  are  composed  of 
non-striped  muscle. 

THE  FLUID  SECRETED  BY  THE  POLYP  OR  FISTULA. 

The  polyp  or  fistula,  as  the  case  may  be,  secretes  a  fluid  which  may  be  watery, 
clear,  and  stringy,  or  cloudy  and  tenacious.  The  amount  varies  greatly.  In  Denuce's 
case,  3  c.c.  were  secreted  in  thirty-six  hours;  in  von  Rosthorn's  case,  5  c.c.  were  dis- 
charged in  twenty-four  hours,  while  in  Tillmanns'  case  2  to  3  c.c.  were  collected  in 
fifteen  minutes.  In  Weber's  case  the  father  estimated  that  half  a  wineglassful  came 
away  daily;  so  abundant  was  the  flow  that  the  child's  clothes  were  soaked. 

In  Denuce's  case,  as  soon  as  the  child  commenced  to  eat,  the  flow  increased,  and 
Tillmanns  drew  attention  to  the  fact  that  irritation  of  the  tumor  in  his  case  caused 
an  abundant  secretion. 
11 


146  THE    UMBILICUS   AND    ITS   DISEASES. 

The  fluid  is  usually  acid.  In  Weber's  case,  however,  it  was  alkaline.  In  Till- 
manns' case  the  fresh  fluid  was  acid,  but  after  it  had  been  kept  for  some  time  it 
became  alkaline. 

Lexer  said  that  in  his  case  the  fluid  chemically  resembled  gastric  juice.  The 
fluid  in  Tillmanns'  case  digested  fibrin  in  an  acid  solution  at  39°  C,  and  Drechsel 
found  that  it  corresponded  to  gastric  juice. 

Yon  Jaksch  made  a  careful  chemical  examination  of  the  fluid  in  von  Rosthorn's 
case,  and  found  albuminous  bodies,  peptone,  pepsin  in  small  quantities,  but  no 
free  hydrochloric  acid.  Denuce  found  free  hydrochloric  acid  and  peptone,  but  no 
pepsin.     He  describes  the  fluid  as  a  "sort  of  gastric  juice." 

From  these  findings  it  is  clear  that  the  fluid  secreted  in  these  cases  bears  a  strong 
resemblance  to  gastric  juice. 

Action  of  the  Fluid  on  the  Skin  Surrounding  the  Umbilicus. — In  von  Rosthorn's 
case  the  abdominal  wall  around  the  umbilicus  was  slightly  irritated. 

In  Tillmanns'  case  the  skin  in  the  vicinity  of  the  polyp  was  macerated.  In 
Denuce's  case  the  skin  surrounding  the  fistula  was  ulcerated  for  a  certain  distance. 
This  ulcerated  area  was  bright  red  in  color,  and  the  tissue  surrounding  it  was  tume- 
fied.    The  total  area  of  ulceration  was  about  the  size  of  a  five-franc  piece. 

In  Reichard's  case,  commencing  just  below  the  fistula  and  extending  downward 
6  cm.  toward  the  pubes,  was  "a  digestive  ulcer"  which  had  indurated  margins. 
The  ulceration  was  situated  just  where  the  fluid  from  the  fistula  trickled  down  the 
abdominal  wall.  The  patient  was  a  child  five  years  old.  He  was  able  to  walk 
around;  hence  the  fluid  flowed  downward  instead  of  irritating  the  parts  all  around 
the  umbilicus. 

Weber's  patient  was  a  boy  three  years  old.  Four  months  before  coming  under 
observation  a  canal-shaped  wound  developed.  This  commenced  at  the  umbilicus 
and  extended  4  cm.  downward  toward  the  symphysis.  It  was  increasing  in 
size  and  had  callous  walls.  The  umbilicus  itself  and  the  surrounding  tissue  over  an 
area  the  size  of  the  palm  of  the  hand  were  markedly  macerated.  The  umbilical 
region  presented  the  typical  picture  of  a  digestive  process. 

The  action  of  the  fluid  alone  would  make  one  strongly  suspect  the  presence  of 
gastric  juice. 

SYMPTOMATOLOGY. 
These  polyps  or  fistulas  are  more  common  in  males  than  in  females.  They  are 
congenital,  and  accordingly  are  usually  noted  at,  or  shortly  after,  the  time  the  cord 
comes  away.  They  are  recognized  by  the  appearance  of  a  small  red  polyp  or  fistula 
at  the  umbilicus.  The  secretion  from  the  navel  varies  in  amount,  is  usually  acid 
in  reaction,  and  tends  to  increase  at  meal-times  or  when  the  polyp  is  mechanically 
irritated.  In  at  least  half  of  the  cases  there  is  more  or  less  digestion  of  the 
abdominal  wall  in  the  umbilical  region.  This  digestive  action  clearly  differentiates 
these  from  ordinary  umbilical  polyps,  and  suggests  the  presence  of  mucosa  identical 
with  or  strongly  resembling  that  of  the  stomach. 

ORIGIN. 
Considerable  speculation  has  been  rife  as  to  the  origin  of  these  so-called  gastric 
polyps  or  fistulas.     Naturally  the  easiest  explanation  would  be  that  in  embryonic 
life  there  has  occurred  a  displacement  of  patches  of  gastric  mucosa. 


SO-CALLED    GASTRIC    MUCOSA    AT    THE    UMBILICUS.  147 

In  Denuce's  case  the  fistulous  tract  was  removed  without  any  opening  into  the 
peritoneum.  The  peritoneum  was  transparent,  and  it  was  possible  to  see  a  little 
to  the  left  of  the  deep  attachment  of  the  fistula  a  cylindric  cord,  which  passed  from 
the  umbilicus  to  a  loop  of  bowel.  This  cord  was  evidently  the  remnant  of  the 
omphalomesenteric  duct. 

In  Reichard's  case  the  abdomen  was  opened  and  the  tumor  found  to  be  cystic, 
bluish,  and  translucent.  Sharply  defined  and  passing  from  it  was  a  very  thin 
pedicle,  which  extended  upward  in  the  abdominal  cavity.  Further  examination 
could  not  be  made  on  account  of  the  weak  condition  of  the  child. 

Weber,  in  removing  the  umbilical  fistulous  tract  in  his  case,  opened  the  peri- 
toneum. From  the  fistulous  tract  a  thin  cord  passed  upward  and  led  to  the  under 
surface  of  the  liver.  He  thought  that  this  cord  represented  the  remains  of  the 
umbilical  vein. 

We  have  no  positive  evidence  in  any  of  the  cases  that  the  umbilical  growth  was 
connected  with  the  stomach.  On  the  other  hand,  it  is  quite  probable  that  in  one 
of  them  it  was  connected  with  the  small  bowel  by  a  fibrous  cord. 

Judging  from  the  embryologic  development  of  the  umbilical  region,  one  would 
naturally  conclude  that  such  growths  are  remnants  of  the  omphalomesenteric  duct. 
Furthermore,  we  learn,  from  the  microscopic  descriptions  of  the  fistula?,  that  in 
some  parts  the  glands  resembled  intestinal  glands;  in  other  places  glands  of  the 
pyloric  region.  Again,  in  Lexer's  case  (Fig.  85)  the  fistulous  tract  was  almost 
continuous  with  a  patent  Meckel's  diverticulum.  The  fistula  was  fined  with  what 
resembled  a  gastric  mucosa;  the  Meckel's  diverticulum,  with  a  mucosa  similar  to 
that  of  the  small  bowel. 

As  is  well  known,  the  entire  digestive  tract  develops  from  the  yolk-sac.  It  has 
been  claimed  that,  prior  to  the  passage  of  the  various  fluids,  such  as  bile  and  pan- 
creatic fluid,  over  the  intestinal  mucosa,  it  is  identical  with  or  bears  a  strong  resem- 
blance to  that  of  the  stomach.  Be  that  as  it  may,  it  is  certain  that  we  have  a  small 
group  of  cases  in  which  polyps  or  fistula?  have  developed  at  the  navel,  and  that 
these  are  covered  or  fined  with  a  mucosa  that  histologically  closely  resembles  gastric 
mucosa;  and  that  this  mucosa  secretes  a  juice  that  acts  very  much  as  gastric  juice 
will  do.  Personally,  I  believe  that  these  growths  are  remnants  of  the  omphalo- 
mesenteric duct. 

TREATMENT. 
Where  a  polyp  exists,  it  is  only  necessary  to  tie  the  pedicle  and  cut  off  the  growth. 
In  those  cases  in  which  a  fistula  exists,  the  umbilicus  should  be  encircled,  the  abdo- 
men opened,  and  the  growth  removed.  If  it  be  connected  with  the  bowel,  the 
intestinal  stump  should  be  treated  as  an  appendix  stump.  In  those  cases  in  which 
much  maceration  exists,  local  alkaline  applications  should  be  employed  until  the 
skin  is  healthy,  after  which  removal  of  the  growth  can  be  readily  carried  out. 


CASES  OF  CONGENITAL  POLYPS  OR  FISTULiE  AT  THE  UMBILICUS  AND  HAVING  A 
MUCOSA  RESEMBLING  THAT  OF  THE  STOMACH. 

A    Pseudopyloric    Congenital    Fistula    at    the    Umbili- 
cus. — ■  Denuce*  speaks  of  a  rare  variety  of  fistula  occurring  at  the  umbilicus. 

*  Denuce:   Fistules  pseudo-pyloriques  congenitales  de  l'ombilic.     Revue  d'orthopedie,  1908, 
xix,  1. 


148  THE    UMBILICUS    AND    ITS    DISEASES. 

A  secretion  is  present,  which  gives  an  acid  reaction,  and  on  chemical  examination 
is  found  to  be  practically  identical  with  gastric  juice.  Moreover,  the  digestive 
action  of  this  fluid  manifests  itself  on  the  tissues  surrounding  the  fistula.  Histo- 
logic examination  shows  that  the  structure  of  the  mucosa  lining  the  fistulous  tract 
is  exactly  similar  to  that  of  the  stomach  and  the  pyloric  region. 

Denuce  saw  a  case  of  this  character  in  the  surgical  clinic  at  Bordeaux,  and  the 
diagnosis  was  made  before  operation.  The  patient,  a  boy  twenty-one  months 
old,  was  admitted  to  the  hospital  on  account  of  a  congenital  umbilical  fistula.  The 
umbilical  cord  in  its  outer  aspect  showed  nothing  abnormal  at  birth.  When  it 
came  away,  there  was  left  what  appeared  to  be  a  granulation  at  the  umbilicus. 
This  was  cauterized.  There  was  a  discharge,  which  at  first  was  slight,  but  later 
at  times  became  very  abundant.  The  fluid,  as  a  rule,  was  colorless,  but  some- 
times it  had  a  hemorrhagic  tint. 

On  admission  the  child's  general  condition  was  poor;  the  fistulous  tract  was 
painful.  Methylene-blue  was  administered,  but  none  was  discharged  from  the 
fistula,  showing  that  the  latter  was  not  urinary  in  character.  Urination  was  nor- 
mal. Digestion  was  normal  and  the  bowels  moved  regularly.  At  the  umbilicus 
was  a  small  orifice  from  which  there  came  a  liquid  discharge.  The  surrounding 
skin  was  ulcerated  for  some  distance.  This  ulcerated  area  had  a  bright-red  color, 
and  the  tissue  around  it  was  tumefied.  At  the  summit  of  the  ulceration  was  a 
fistulous  orifice.  The  total  area  of  ulceration  at  the  umbilicus  was  about  the  size 
of  a  five-franc  piece.  A  probe  could  be  introduced  into  the  fistula  for  about  1.5 
cm.  The  fluid,  when  first  examined,  was  clear,  but  when  the  child  started- to  eat, 
there  was  an  immediate  increase  in  the  quantity  of  the  discharge  from  the  umbilicus. 
In  about  thirty-six  hours  3  c.c.  of  liquid  were  secured.  An  analysis  of  this  fluid 
gave  the  following: 

Glucose 0 

Sulphocyanid 0 

Albumin + 

Lactic  acid 0 

Free  hydrochloric  acid + 

Peptone + 

Lab  ferment 0 

Pepsin 0 

Further  examination  of  the  " gastric  juice"  from  the  same  patient  showed  an 
estimated  total  acidity  of  2.4  gm.  to  the  liter.  The  presence  of  free  hydrochloric 
acid,  peptone,  and  lab  ferment  was  detected.  The  conclusions  drawn  were  that 
this  liquid  might  be  considered  as  a  sort  of  gastric  juice. 

The  fistulous  tract  was  removed  without  any  opening  into  the  peritoneum.  The 
peritoneum  was  transparent,  and  it  was  possible  to  see  a  little  to  the  left  of  the  deep 
portion  of  the  fistula  the  attachment  of  a  cylindric  cord,  which,  at  its  inner  extremity, 
was  inserted  into  one  of  the  intestinal  loops.  It  was  easily  recognized  that  this 
cord  represented  Meckel's  diverticulum,  which,  at  its  distal  extremity,  was  attached 
to  the  umbilicus.  The  umbilical  fistula  was  ligated  at  its  base  and  burned  off  with 
the  thermocautery.     The  child  made  a  good  recovery. 

Sections  through  the  fistulous  tract  showed  a  mucous  structure  analogous  to 
that  of  the  stomach.  Fig.  83  represents  a  transverse  section  of  the  fistulous  tract. 
Owing  to  the  presence  of  the  villus-like  projections  the  general  appearance  of  this 


SO-CALLED    GASTRIC    MUCOSA    AT    THE    UMBILICUS. 


149 


tract  reminds  one  somewhat  of  the  Fallopian  tube  projections.  The  cavity  contained 
granular  remains,  and  round  or  oval  cells.  The  fistula  might  be  described  as  a  sort 
of  small  cul-de-sac  lined  with  a  kind  of  gastric  mucosa.  Denuce  speaks  of  this  case 
as  an  instance  of  pseudopylorus,  and  says  such  cases  are  exceedingly  rare.  He 
then  goes  on  to  discuss  the  cases  of  Tillmanns  and  Roser,  and  considers  the  various 
hypotheses  as  to  the  origin  of  these  fistulae.  In  young  embryos,  he  points  out,  the 
intestinal  tract  is  lined  with  epithelium  which  is  the  same  throughout,  and  the 
differentiation  between  the  epithelium  of  the  stomach  and  that  of  the  intestine  is  a 
later  development. 


WKt/rJfc 


u 


w 


Fig.  83. — Transverse  Section-  of  a  Pseudopyloric  Congenita!  Fistula  at  the  Umbilicus.     (After  Denuce.) 
The  mucosa  resembled  somewhat  that  of  the  intestine,  somewhat  that  of  the  stomach.     The  finger-like  and  papillary- 
outgrowths  are,  however,  unusually  long.     For  the  appearances  under  the  high  power  see  Fig.  84. 


Gastric  Mucosa  in  a  Persistent  Omphalomesenteric 
Duct  .  —  Lexer*  says  there  is  a  small  group  of  cases  which,  on  account  of  their 
individual  structure  and  the  character  of  the  mucous  lining,  are  obscure.  These 
cases  have  a  mucosa  that  not  only  closely  resembles  that  of  the  pyloric  region  but 
also  secretes  a  fluid  resembling  gastric  juice.  He  then  refers  to  the  cases  of  Tillmanns 
and  Siegenbeek  van  Heukelom. 

Lexer's  patient  was  one  year  old.  It  had  a  congenital  umbilical  fistula,  and  the 
surrounding  skin  was  eroded.  The  fluid  which  was  collected  for  several  hours  was 
clear,  stringy,  contained  no  intestinal  contents,  was  strongly  acid,  and  chemically 


*  Lexer:    Magenschleirrihaut  im  persist irenden  Dottergang. 
Chir.,  1899,  lix,  859. 


Lanaenbeck's  Arch.  f.  klin. 


150 


THE    UMBILICUS   AND    ITS    DISEASES. 


resembled  stomach  juice.  It  rapidly  digested  albumen  (fibrin).  At  operation  the 
fistulous  tract  was  found  attached  to  the  convexity  of  the  small  bowel  (Fig.  85). 
It  closed  at  a  point  1.5  cm.  behind  the  umbilicus.  Meckel's  diverticulum  was 
lined  with  intestinal  mucosa,  but  that  of  the  umbilical  portion  of  the  fistula  was 
totally  different,  consisting  of  what  Lexer  termed  pseudopyloric  mucous  mem- 
brane. The  cylindric  epithelium  lining  the  outer  portion  of  the  fistula  was  high, 
and  the  mucosa  itself  resembled  that  of  the  pylorus,  but  was  drawn  out  into  finger- 
like projections. 

According  to  Lexer,  the  picture  as  a  whole  demonstrated  the  persistence  of  the 

omphalomesenteric  duct,  the  outer  portion 
of  which  differed  entirely  from  that  com- 
municating with  the  bowel.  This  variation 
in  type,  he  thought,  is  probably  due  to  an 
early  severance  of  the  outer  portion  of  the 
fistulous  tract  from  the  inner  portion. 

An    Umbilical    Polyp.  —  Minelli* 

gives  a  low-power  picture  showing  a  tumor 

l  which  suggested  an  adenoma  of  the  umbili- 

(        ,,':•"  cus.     He  then  gives  a  resume  of  the  liter- 


U 


/ 

/"* 

J'i 


Fig.  S4. — High-power  Picture  of  a  Fistulous 
Tract  at  the  Umbilicus,  Showing  Glands 
Resembling  those  of  the  Pylorus.  (After 
DenucS.) 

1,  Excretory  glands:  2,  2,  2,  2,  acini;  3,  3, 
cells  bordering  acini;  4,  4,  eosinophiles;  5,  5, 
mast  cells;    6,  island  of  lymphoid  tissue. 


Fig.  85. — An  Umbilical  Fistula  Lined  with  Mucosa  Re- 
sembling that  of  the  Stomach.  (After  Lexer.) 
This  sketch  is  from  Plate  16  accompanying  Lexer's  article. 
It  shows  the  lack  of  continuity  of  the  fistulous  tract.  The  inner 
portion  is  from  Meckel's  diverticulum,  and  is  lined  with  a  mu- 
cosa like  that  of  the  small  bowel.  The  outer  portion  of  the  tract 
was  cut  off  entirely  from  the  inner  and  was  lined  with  mucosa 
resembling  that  of  the  pylorus. 


ature.     His  was  a  congenital  tumor,  which  later  had  increased  to  the  size  of  a 
walnut.     Histologically,  it  presented  the  picture  of  a  gastric  adenoma. 

A  Cystic  Umbilical  Tumor  Secreting  a  Fluid  that 
Tended  to  Digest  the  Abdominal  Wall.f  —  In  the  case  of  a 
boy  five  years  old,  moisture  had  been  noticed  in  the  umbilical  region  since  his  birth. 
Four  months  before  entering  the  hospital  he  developed  a  serpiginous  ulcer,  which 
extended  from  the  umbilicus  downward.     On  admission  the  child  was  pale.     In  the 

*  Minelli,  S.:  Adenoma  Ombelicale  a  struttura  gastrica.     Gaz.  med.  Italiana,  1905,  lvi,  101. 
t  Reichard:  Centralbl.  f.  Chir.,  1898,  xxv,  587. 


SO-CALLED    GASTRIC   MUCOSA   AT   THE    UMBILICUS.  151 

umbilical  region  was  a  tumor,  the  size  of  a  hazel-nut,  which  showed  a  fine  fistulous 
opening  from  which  clear  fluid  escaped.  The  digestive  ulcer  extended  down  the 
abdominal  wall  for  a  distance  of  6  cm.     Its  margins  were  indurated. 

The  abdomen  was  opened,  and  the  tumor  was  found  to  be  cystic,  bluish,  trans- 
lucent, and  sharply  defined.  Passing  from  it  was  a  very  thin  pedicle  which  extended 
upward  in  the  abdominal  cavity.  Further  examination  could  not  be  made  on 
account  of  the  weak  condition  of  the  child.  The  entire  umbilical  area  was  removed, 
and  the  child  recovered. 

The  cavity  was  lined  with  mucosa  which  microscopically  seemed  to  be  of  the 
gastric  type.  Reichard  says  that  this  reminded  him  of  Tillmanns'  case,  although 
neither  inversion  nor  prolapsus  of  the  tumor  had  occurred. 

An  Umbilical  Fistula.*  —  The  boy,  a  year  and  a  half  old,  entered 
the  hospital  November  4,  1886.  The  umbilicus  was  swollen,  and  from  it  an  acid, 
watery  fluid  escaped.  The  surrounding  tissue  was  slightly  macerated.  The  open- 
ing at  the  umbilicus  was  red  and  granular,  and  the  walls  were  indurated  and  thick- 
ened.    The  cavity  was  1  cm.  in  diameter. 

Operation. — The  thickened  skin  was  cut  out  and  the  red,  granulating  mucosa 
removed  with  forceps  and  scissors.  Roser  thought  that  he  had  cut  down  to  the  sub- 
peritoneal connective  tissue  and  did  not  enter  the  abdominal  cavity.  Several  weeks 
later  he  noticed  that  some  of  the  mucosa  had  been  left  behind,  and  a  sound  could  be 
carried  3  mm.  downward.  The  discharge  was  small  in  amount,  but  slightly  acid 
in  reaction.  A  small  tampon  saturated  with  a  solution  of  zinc  chlorid  was  placed 
in  the  cavity,  and  several  weeks  later  all  trace  of  the  fistula  had  disappeared.  The 
scar  was  hardly  visible  when  the  child  left  the  hospital  in  December. 

Microscopic  examination  by  Professor  Marchand  showed  that  the  mucosa  was 
similar  to  that  of  the  stomach.  The  tubular  glands  were  closely  packed,  and  be- 
neath them  was  an  abundant  layer  of  smooth  muscle. 

Roser  says  that  when  one  remembers  that,  in  the  early  fetal  life,  the  pylorus  is 
in  a  different  position  to  that  which  it  occupies  later, — that  is  to  say,  the  stomach  is 
perpendicular,  and  the  pylorus  is  in  the  umbilical  region, — one  can  surmise  that  a 
portion  of  the  wall  of  the  stomach  may  be  detained  at  the  umbilicus  and  when  the 
stomach  draws  back,  may  be  held  there.  In  this  way  a  diverticulum  might  form, 
and  as  a  result  a  cyst  would  develop. 

A  Congenital  Umbilical  Fistula,  f  — A  boy,  seven  years  old, 
was  admitted  on  account  of  an  umbilical  fistula.  Its  presence  had  been  noted  when 
the  cord  dropped  off.  On  the  fourth  day  a  projection  4  cm.  long  and  of  about  the 
thickness  of  a  little  finger  was  noted  at  the  umbilicus.  It  was  glassy  in  appearance 
and  pale.  In  the  course  of  a  month  a  small  opening  developed  in  the  center  of  it, 
from  which  came  a  continuous  flow  of  clear,  watery  fluid.  The  projection  gradually 
diminished  until  it  disappeared,  but  the  opening  grew  larger  until  its  diameter 
reached  that  of  a  penholder.  No  feces,  no  fecal  odor,  and  no  urine  were  at  any  time 
detected  at  the  umbilicus. 

On  admission  the  boy  was  strong  and  well  nourished.  At  the  umbilicus  was  a 
tumor  the  size  of  a  hazel-nut.     It  was  round,  red,  and  glistening,  1  cm.  in  diameter, 

*  Roser,  W.:  Zur  Lehre  von  der  umbilikalen  Magencvstenfistel.  Centralbl.  f.  Chir.,  1887, 
xiv,  260. 

t  Von  Rosthorn:  Ein  Beitrag  zur  Kenntniss  der  angeborenen  Nabelfisteln.  Wien.  klin. 
Wochenschr.,  1889,  ii,  125. 


152  THE    UMBILICUS   AND    ITS    DISEASES. 

soft  in  consistence,  and  had  a  velvety  covering.  Through  the  central  opening  a 
probe  could  be  passed  directly  inward  for  2  cm.  The  abdominal  wall  around  the 
opening  was  slightly  irritated. 

The  secretion  from  the  umbilical  tumor  amounted  to  about  5  c.c.  in  twenty- 
four  hours.     It  was  acid  in  reaction.     Von  Jaksch  made  the  chemical  examination. 
Organic  :     Albumin  bodies,    peptone   and  albumose,   ferments   and 
pepsin,  in  small  quantity;   sugar,  urinary  salts,  bile-coloring  matter, 
urobilin,  absent. 
Inorganic  :    Reaction  for  free  hydrochloric  acid  negative.     Chlorids 
in  large  quantities.     No  phosphates  or  sulphates. 
Microscopic  examination  of  the  diverticulum,  which  extended  to  the  peritoneum, 
showed  typical  Lieberkuhn's  glands;    near  the  middle  portion  were  glands  with 
clear  cells  resembling  closely  those  of  the  pyloric  region. 

A  Congenital  Umbilical  Fistula  Lined  with  a  Mucosa 
Possibly  Resembling  that  of  the  Stomach.*  —  The  child,  two 
and  one-half  years  old,  had  had  trouble  at  the  umbilicus  since  the  cord  came  away. 
The  umbilical  region  was  never  dry,  and  in  the  depression  was  a  tumor  the  size  of  a 

hazelnut,  red  in  color,  and  with  a  granular,  moist  sur- 
face.  It  was  attached  to  the  umbilical  depression  by 
a  short,  thin  pedicle.  It  looked  like  a  typical  granu- 
•d  loma  of  the  umbilicus.  The  pedicle  was  cut,  but  so 
much  oozing  took  place  that  the  thermocautery  was 
necessary  to  check  the  bleeding.     On  microscopic  ex- 

Fig.  86. — Appearance  of  the  Um-  _  "  °  x 

bilical  depression  in  von        animation  a  transverse  section  of  the  polyp  showed 
rosthorn's  case.  ^at  the  surface  was  covered  with  glands.     The  cen- 

o,  the  umbilical  opening;     b,  the  ,       ■>  ,.  •    .l     1       c         i  •  i     ,•  ,     •     • 

bottom  of  the  depression;  c,  the  peri-  tral  portion  consisted  of  adenoid  tissue  contaimng 
toneum.  many  smooth  muscle-fibers.     The  epithelium   and 

glands  of  the  tumor  resembled  those  of  the  intestine. 

An  Umbilical  Polyp.  —  Stradaf  gives  a  short  survey  of  the  literature, 
and  then  reports  the  case  of  a  young  woman  of  twenty  who  had  a  tumor  at  the  um- 
bilicus. This  grew  slowly  to  the  size  of  a  walnut,  was  round,  red,  and  covered  with 
mucosa.     It  was  attached  by  a  short  pedicle  and  was  irreducible.     It  was  removed. 

On  microscopic  examination  it  was  found  to  be  covered  with  cylindric  epithelium. 
The  majority  of  the  glands,  according  to  Strada,  were  of  the  pyloric  type;  others 
resembled  Lieberkuhn's  glands.  In  the  center  of  the  tumor  was  adipose  tissue; 
surrounding  it,  non-striped  muscle.  Strada  gives  a  splendid  picture  of  this  case, 
and  then  carefully  reviews  the  cases  in  which  the  mucosa  at  the  umbilicus  resembled 
gastric  mucosa. 

Congenital  Prolapsus  of  Stomach  Mucosa  Through 
the  Umbilical  R  i  n  g  .  % —  In  July,  1881,  August  W.,  aged  thirteen,  was 
brought  to  Tillmanns.  With  the  exception  of  an  unusual  condition  at  the  umbili- 
cus, the  child  was  perfectly  healthy,  although  somewhat  anemic. 

*  Siegenbeek  van  Heukelom:  Die  Genese  cler  Ectopia  ventriculi  am  Nabel.  Virchows  Arch., 
1888,  cxi,  §475. 

Strada,    Ferdinando:   Adenoma  Congenito  Ombelicale  a  tipo  gastrico.    Lo  Sperimentale 
Archivio  di  biologia  normale  e  patologia,  1903,  lvii,  637. 

|  Tillmanns,  H.:  Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring 
(Ectopia  Ventriculi;  und  iiber  sonstige  Geschwtilste  und  Fisteln  des  Nabels.  Deutsche  Zeitschr. 
f.  Chir.,  1882-83,  xviii,  161. 


SO-CALLED    GASTRIC    MUCOSA    AT    THE    UMBILICUS. 


153 


At  the  umbilicus  was  a  bright-red  tumor  the  size  of  a  walnut  (Fig.  87j.  It 
was  painless  on  manipulation,  but  caused  the  patient  some  feeling  of  discomfort. 
The  surface  of  the  tumor  secreted  a  cloudy,  tenacious,  mucus-like  acid  juice,  which 
was  especially  abundant  when  the  tumor  was  irritated.  At  no  point  was  there 
any  evidence  of  an  opening  downward,  and  no  canal  could  be  made  out.  The  entire 
tumor  was  covered  with  mucosa.  It  was  attached  to  the  umbilicus  by  a  thin 
pedicle.  It  was  not  increased  in  size  by  coughing  or  by  pressure  on  the  ab- 
dominal wall.  The  skin  in  the  vicinity  of  the  tumor  had  been  macerated  by 
the  secretion. 

The  secretion  was  relatively  abundant.     It  was  possible,  in  the  course  of  fifteen 
minutes,  to  collect  from  2  to  3  c.c.  and,  when  the  tumor  was  mechanically  irritated 
with  the  ringer  or  a  sound,  the  secretion  increased.     Tillmanns  first  thought  that  he 
was  dealing  with  a  Meckel's  di- 
verticulum with  prolapse  of  the 
intestinal    mucosa,    or    possibly 
that   a  urachal    fistula   existed. 
Thiersch  also  saw  the  boy  and 
came  to  the  same  conclusion,  but 
the  acid  reaction  of  the  mucus, 
the  experiments  as  to  its  power 
of  digestion,  and  later  the  histo- 
logic examination  of  the  tumor, 
made  them  conclude  that  they 
had  to  deal  with  stomach  mucosa. 

The  secretion  digested  fibrin 
in  an  acid  solution  at  39°  C.  Pep- 
sin was  evidently  present.  The 
fresh  secretion  was  strongly  acid. 
That  which  had  been  secreted  for 
some  time  and  lay  in  the  vicinity 
of  the  tumor  in  several  instances 
gave  an  alkaline  reaction.  Pro- 
fessor Drechsel,  of  the  Chemical 
Department,  examined  the  secre- 
tion and  found  that  it  corres- 
ponded to  that  coming  from  the 
stomach. 

The  mother  said  that  the  cord  dropped  off  about  the  sixth  day,  and  that  im- 
mediately a  reddish  tumor,  about  the  size  of  a  cherry,  was  seen  at  the  umbilicus. 
The  umbilical  cord  was  unusually  thick,  and  it  was  thought  possible  that  the  mid- 
wife had  tied  the  cord  too  close  to  the  umbilical  ring.  Several  days  after  the 
cord  had  come  away  the  tumor  became  more  prominent.  During  the  last  few  years 
it  had  grown  very  slowly,  and  in  the  four  months  previous  to  his  admission  there 
had  been  hardly  any  increase  in  size.  After  the  boy  had  eaten,  this  tumor  would 
sometimes  swell  perceptibly;  it  would  become  reddish,  and  the  mucosa  would  in- 
crease in  thickness.  At  this  time  it  would  also  secrete  abundantly.  The  discharge 
had  been  so  copious  that  it  was  necessary  for  the  patient  to  wear  dressings.  These 
would  sometimes  be  saturated  and  his  clothes  would  be  wet.     There  was  no  evi- 


Fig.  8.. — Gastric  Mucosa  at  the  Umbilicus.  (After  Till- 
manns.) 
Projecting  from  the  umbilicus  is  a  bright-red,  velvety  tumor 
mass.  This  was  covered  over  "with  mucosa,  which  on  histologic 
examination  resembled  mucosa  of  the  pyloric  region.  It  had  an 
abundant  secretion. 


154 


THE    UMBILICUS    AXD    ITS    DISEASES. 


dence  of  fecal  matter  or  of  stomach-contents  at  the  umbilicus.     The  boy  had  never 
suffered  from  indigestion,  and  his  defecation  was  normal. 

On  account  of  the  discharge  the  boy  was  anxious  to  have  the  tumor  removed. 
This  was  readily  accomplished.  The  pedicle  was  cut  across,  and  the  few  small 
vessels  were  controlled  with  the  Paquelin  cautery.  Within  a  few  days  all  trace 
had  disappeared,  and  the  patient,  up  to  the  time  Tillmanns  reported  the  case,  had 
been  perfectly  well  (Fig.  88). 

Microscopic  examination  of  the  tumor  by  Professor  Weigert  showed  that  it 
consisted  of  stomach-wall,  all  the  layers  being  present.  In  the  center  was  serosa, 
then  came  subserosa,  then  a  layer  of  muscle,  and  covering  the  outer  surface,  mucosa. 
The  glands  were  very  abundant,  but  were  in  part  atrophic.  Several  portions  on 
casual  examination  might  very  readily  have  been  mistaken  for  intestinal  mucosa; 
but  others  at  once  indicated  their  origin  from  the  pylorus. 

Tillmanns  says  that,  from  the  chemical  and  anatomic  examination,  it  was  evident 
that  a  portion  of  the  stomach-wall  in  the  vicinity  of  the  pjdorus  had  prolapsed 

through  the  umbilical  ring  in  such  a  way 
that  the  mucosa  was  on  the  outer  surface, 
while  the  muscular  coats  formed  the  cen- 
ter. He  said  he  was  unable  to  find  a 
similar  case  reported  in  the  literature. 
To  explain  the  origin  of  the  condition  he 
supposed  that  there  had  probably  been 
an  umbilical  hernia,  in  which  a  portion 
of  the  stomach  diverticulum  had  been  in- 
cluded; that  the  thick,  funnel-shaped 
umbilicus  had  probably  been  tied  too 
close  to  the  umbilical  ring,  and  in  all 
probability  a  portion  of  the  stomach 
diverticulum  had  been  tied  off  with  the 
cord.  He  added  that,  at  the  time  of 
labor,  the  diverticulum  of  the  stomach 
was  probably  no  longer  in  connection 
with  the  stomach  proper. 
An  Umbilical  P  o  1  y  p  Covered  with  Stomach  Mucosa.* 
— A  boy,  three  3-ears  old,  was  admitted  January  5,  1897.  The  labor  had  been 
normal,  but  the  cord  did  not  come  away  on  time.  When  it  did  drop  off,  a  small, 
red  tumor  was  found  at  the  umbilicus.  This  was  cauterized  by  the  attending 
physician.  From  that  time  it  secreted  a  fluid  which  was  whitish  and  contained 
brown  flocculi  or  white  clots,  and  occasionally  mucous  threads.  There  was  never 
any  indication  of  the  escape  of  intestinal  or  stomach-contents.  According  to  the 
father,  about  half  a  wineglassful  of  fluid  escaped  daily.  The  clothes  and  dress- 
ing were  always  soaked. 

The  flow  increased  at  midday,  and  at  that  time  was  often  accompanied  by 
colicky  pain.     In  the  morning,  on  the  other  hand,  the  child  was  comfortable. 

Four  months  before  his  admission  a  canal-shaped  wound  developed  from  the 
umbilicus  downward.  This  would  not  heal,  but  continued  to  increase  in  size. 
The  boy's  appetite  was  good;  the  bowels  were  regular. 

*  Weber,  W. :  Zur  Kasuistik  der  Ectopia  ventriculi.     Beitrage  z.  klin.  Chir.,  1898,  xxii,  371. 


Fig.  88. — Appearance  of  the  Umbilicus  after  Re- 
moval of  the  Stomach  Mucosa  seen  in  Fig.  87. 
-  Tillmanns.; 
The  umbilical  depression  is  very  uneven,  but  perfectly 
intact.     There  was  no  opening  into  the  abdomen. 


SO-CALLED    GASTRIC   MUCOSA   AT   THE   UMBILICUS.  155 

On  admission  the  child  was  anemic.  On  separation  of  the  umbilical  folds  a 
drop  of  clear,  serous  fluid  escaped.  Passing  down  the  abdominal  wall  from  this 
point  was  a  canal-shaped,  ulcerated  area,  about  four  cm.  long,  having  callous  walls. 
The  wound  itself  and  the  surrounding  epidermis  over  an  area  the  size  of  the  palm  of 
the  hand  were  markedly  macerated.  The  umbilical  region  presented  the  typical 
picture  of  a  digestive  process. 

Operation. — An  incision  including  this  area  was  made  and  the  peritoneum 
opened.  From  the  fistulous  tract  a  thin  cord  passed  upward  and  led  to  the  under 
surface  of  the  liver.  The  umbilical  growth  was  sharply  defined,  bluish,  and  cystic. 
There  was  no  connection  with  the  intestine  or  with  the  stomach.  The  tumor  was 
removed.     In  three  weeks  only  two  small  areas  of  granulation  remained. 

The  cystic  tumor  was  lined  with  a  thick  mucosa,  macroscopically  resembling 
that  of  the  stomach.  The  mucosa  was  alkaline  in  reaction.  On  microscopic 
examination  it  was  found  to  be  of  the  pyloric  type.  Beneath  it  was  a  submucosa, 
then  layers  of  non-striped  muscle.  Weber  says  that,  from  this  description  and  the 
microscopic  picture,  it  is  certain  that  we  are  dealing  with  normal  stomach  mucosa 
from  the  pyloric  region.  The  microscopic  examination  was  made  in  the  Berlin 
Pathological  Laboratory  by  Privatdocent  Krause. 

Weber  thought  that  the  cord  passing  to  the  under  surface  of  the  liver  represented 
remains  of  the  umbilical  vein. 

Although  the  secretion  was  alkaline,  the  free  secretion  at  noontime,  and  the 
maceration,  together  with  the  anatomic  appearance  above  noted,  indicated  that 
the  growth  had  developed  from  the  stomach.  Weber  gives  a  resume  of  the  litera- 
ture on  the  subject. 


LITERATURE  CONSULTED  ON  CONGENITAL  POLYPS,  FISTULiE,  OR  CYSTIC  DILA- 
TATIONS AT  THE  UMBILICUS,  SHOWING  A  MUCOSA  MORE  OR  LESS  SIMILAR 
TO  THAT  OF  THE  PYLORIC  REGION  OF  THE  STOMACH,  AND  SECRETING  AN 
IRRITATING  FLUID  BEARING  A  MARKED  RESEMBLANCE  TO  GASTRIC  JUICE. 

Denuce:  Fistules  pseudo-pyloriques  congenitales  de  l'ombilic.     Revue  d'orthopedie,  1908,  xix,  1. 
Lexer:    Magenschleimhaut  im  persistirenden  Dottergang.     Langenbeck's  Arch.  f.  klin.  Chir., 

1S99,  lix,  859. 
Minelli,  S.:  Adenoma  Ombelicale  a  struttura  gastrica.     Gaz.  med.  Italiana,  1905,  lvi,  101. 
Reichard:   Centralbl.  f.  Chir.,  1898,  xxv,  587. 

Roser:  Zur  Lehre  von  der  umbilikalen  Magencystenfistel.     Centralbl.  f.  Chir.,  1887,  xiv,  260. 
Von  Rosthorn:  Ein  Beitrag  zur  Kenntnis  der  angeborenen  Nabelfisteln.    Wien.  klin.  Wochenschr., 

1889,  ii,  125. 
Siegenbeek  van  Heukelom:  Die  Genese  der  Ectopia  ventriculi  am  Nabel.     Virchows  Arch.,  1888, 

cxi,  475. 
Strada,  F.:   Adenoma  Congenito  Ombelicale  a  tipo  gastrico.     Lo  Sperimentale  Archivio  di  bio- 

logia  normale  e  patologia,  1903,  lvii,  637. 
Tillmanns,  H. :  Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring  (Ectopia 

Ventriculi)  und  iiber  sonstige  Geschwulste  und  Fisteln  des  Nabels.     Deutsche  Zeitschr.  f. 

Chir.,  1882-83,  xviii,  161. 
Weber,  W.:  Zur  Kasuistik  der  Ectopia  ventriculi.     Beitrage  z.  klin.  Chir.,  189S,  xxii,  371. 

PERSISTENCE  OF  THE  OUTER  PORTION  OF  THE  OMPHALOMESENTERIC  DUCT. 

The  picture   presented  is  practically  the  same  as  where  a  simple  umbilical 

polyp  exists.     (See  Fig.  89.)     Situated  at  the  umbilicus  is  a  red  nodule,  varying 

from  a  pea  to  a  chestnut  in  size.     Occasionally  it  may  be  longer,  as  in  Wheaton's 


156 


THE    UMBILICUS    AND    ITS    DISEASES. 


case.     In  Chandelux'  case  it  was  6  cm.  long.     This  length,  of  course,  is  excep- 
tional. 

Occupying  the  center  of  the  prominent  part  of  the  nodule  is  a  canal,  into  which 
a  sound  can  be  introduced  (Figs.  89,  90,  and  91),  sometimes  only  for  a  short  dis- 


Fig.  89. — Persistence  of  the  Outer  End  of  the 
Omphalomesenteric  Duct.  (Schematic.) 
The  persistence  of  the  outer  end  of  the  omphalo- 
mesenteric duct  as  a  wide  funnel  is  most  unusual,  but 
has  occasionally  been  noted.  The  duct  can  be  traced 
for  about  half  its  length,  and  then  ends  in  a  fibrous  cord 
which  extends  to  and  is  adherent  to  the  convex  surface 
of  the  bowel. 


Polyp 


Fig.  90. — Atrophy  of  the  Inner  End  of  the  Om- 
phalomesenteric Duct.  (Schematic.) 
At  the  umbilicus  is  a  polyp-like  outgrowth  covered 
with  intestinal  mucosa  in  the  center  of  which  is  a  canal 
— the  outer  end  of  the  omphalomesenteric  duct.  The 
intra-abdominal  portion  of  the  duct  is  represented  by  a 
fibrous  cord  which  extends  from  the  umbilical  region  to 
the  convex  surface  of  the  bowel. 


tance,  usually  for  from  1.5  to  2.5  cm.  From  the  fistula  a  glairy  mucus  or  a  clear 
fluid  escapes.  In  one  of  Florentin's  cases  the  fluid  coagulated,  resembling  apple 
jelly.  In  this  case,  in  addition  to  the  fistula,  there  was  a  pus-pocket,  the  size  of 
a  small  mandarin  orange,  lying  to  one  side  of  the  fistulous  tract.  These  projec- 
tions, and  also  the  fistulous  tract,  are  covered  with 
mucosa  of  the  small  bowel. 

The  condition  is  usually  noted  at  the  time  that 
the  cord  comes  away,  or  shortly  afterward. 

When  the  abdomen  is  opened  for  the  removal 
of  the  umbilical  fistula,  the  abdominal  end  of  the 
tract  will  usually  be  found  to  end  in  a  fibrous  cord, 
which  is  attached  to  the  convex  surface  of  the  small 
bowel.  When  removing  the  fistula  it  is  always  wise 
to  treat  the  stump  at  the  bowel  as  a  patent  tube,  as 
one  never  knows  when  a  fistulous  tract  or  a  thick 
adhesion  may  contain  a  minute  opening  that  con- 
nects with  the  lumen  of  the  bowel. 


Fig.  91. 


-A  Long  Umbilical  Poltp  as 
a    Remnant    of    the    Omphalo- 
mesenteric Duct.       (Schematic.) 
A  short,  round  umbilical  polyp  is 
the  most  common  remnant  of  the  duct 
noted  clinically.    Such  a  long  penile  pro- 
jection as  here  depicted  is  exceptional. 
In  such  a  case  as  this  there  is  a  long  red- 
dish projection  springing  from  the  um- 
bilical depression.     It  is  covered  with 
intestinal  mucosa.     In  its  center  is   a 
fistulous  opening  into  which   a   probe 
can  be  carried  for  a  variable  distance. 
Traces  of  the  intra-abdominal  portion 
of  the  duct  may  or  may  not  be  present. 


Cases 


IN    WHICH   THE   OUTER   END   OF    THE    OMPHALO- 
MESENTERIC Duct  Remained  Patent. 

Persistence  of  the  Outer  Por- 
tion of  the  Omphalomesenteric 
Duct.*  —  A  child,  two  and  one-half  years  old, 
had  had  at  the  umbilicus,  since  birth,  a  projection,  about  6  cm.  long,  resembling  a 
portion  of  umbilical  cord.  When  the  child  was  admitted  to  the  hospital,  the  growth 
was  still  about  0  cm.  in  length.  Its  extremity  was  free  and  somewhat  enlarged.  In  its 
center  was  a  slight  depression  which  admitted  a  probe  for  a  short  distance.     The 

Chandelux,   A.:   Observation  pour  servir  a  l'histoire  de  l'exomphale.    Arch,  de  physiol. 
norm,  et  pathologique,  1881,  xiii,  2.  ser.,  93. 


PATENT   OUTER   PORTION   OF   OMPHALOMESENTERIC   DUCT.  157 

growth  bore  some  resemblance  to  a  penis.  The  surface  was  not  smooth,  but  had  a 
granular  aspect  and  was  reddish  in  color.  Here  and  there  were  pale  areas  suggest- 
ing islands  of  skin.  Its  surface  was  covered  with  an  abundant  viscid  discharge. 
This  was  never  yellow,  nor  could  a  fecal  odor  be  detected.  Urination  was  normal. 
The  nodule  could  not  be  reduced  by  taxis.  The  patient's  health  was  good.  This 
nodule  was  successfully  removed.  On  histologic  examination  its  outer  surface  was 
found  to  be  covered  with  intestinal  mucosa,  and  its  central  portion  was  made  up  of 
non-striped  muscle. 

A  Partially  Patent  Omphalomesenteric  Duct.  —  Flor- 
entin* refers  to  a  boy,  five  weeks  old,  who  came  to  Professor  Froelich's  clinic. 
The  cord  had  been  ligated  3  cm.  from  the  umbilicus.  Eight  days  after  birth, 
when  the  cord  came  away,  a  small  umbilical  tumor  was  noted  which  discharged 
a  clear  liquid.  The  nodule  did  not  change  in  volume  and  was  not  painful. 
When  the  child  came  to  the  clinic,  the  umbilicus  looked  somewhat  tumefied,  and 
in  its  center  was  a  small  pedunculated  tumor  about  the  size  of  a  pea.  It  was 
dark  red,  firm,  irreducible,  and  showed  but  little  tendency  to  bleed.  In  its  center 
was  a  small  depression  from  which  mucus  escaped  in  small  amount.  A  probe 
could  be  introduced  for  2  cm.     The  fistulous  tract  was  removed. 

It  was  found  to  be  continuous  with  a  cord,  which  was  implanted  in  the  in- 
testine. This  cord  was  cut  off  near  the  intestine  with  the  thermocautery,  covered 
over,  and  the  abdomen  was  closed.  The  child  made  a  good  recovery.  The  outer 
surface  of  the  tumor  was  covered  with  Lieberkuhn's  glands,  and  the  cord  itself 
presented  a  lumen  lined  with  cylindric  epithelium.  This  tumor  was  a  partially 
patent  omphalomesenteric  duct. 

A  Partially  Patent  Omphalomesenteric  Duct.  —  Flor- 
entinf  refers  to  an  umbilical  fungus  in  a  child  two  months  old  in  Froelich's  clinic. 
Just  as  soon  as  the  cord  came  away  a  small  reddish  mass,  the  size  of  a  pea,  was 
noted  at  the  umbilicus.  There  was  no  history  of  intestinal  trouble.  The  umbilical 
nodule  did  not  increase  in  size.  It  was  firm,  hard,  and  did  not  resemble  a  simple 
granulation.  It  had  a  short  pedicle.  It  was  dark  red  in  color,  smooth,  and  only 
slightly  painful.  It  was  irreducible.  At  its  summit  was  a  fistulous  tract  from 
which  a  small  amount  of  clear  liquid  without  odor  escaped.  A  probe  could  be 
introduced  for  3  cm. 

At  operation  it  was  found  that  the  under  portion  of  this  fistulous  tract  was 
adherent  to  a  cord,  and  that  the  base  of  it  was  attached  to  the  intestine.  This 
cord  was  burned  off,  and  the  base  turned  in  as  in  an  appendix  operation. 

Histologic  examination  showed  that  the  outer  or  umbilical  surface  of  the  fistula 
was  covered  with  glands,  beneath  which  was  muscle.  The  condition  was  due  to  a 
partially  patent  omphalomesenteric  duct. 

Umbilical  Polyp  with  a  Partially  Patent  Omphalo- 
mesenteric Duct.  —  Florentin  J  describes  a  fungous  diverticulum  with  a 
fistula  at  the  umbilicus  and  a  pocket  of  pus,  in  a  boy  one  year  old.  This  patient 
was  observed  in  Froelich's  clinic.  After  the  cord  came  away  a  tumor  of  consider- 
able size  was  found  at  the  umbilicus.  It  discharged  a  clear  liquid  similar  to  apple 
jelly.     After  the  third  month  the  fistula  closed,  but  it  reopened  four  months  later, 

*  Florentin,  P. :  Fongus  de  l'ombilic  chez  le  nouveau-ne'  et  chez  l'enfant.  These  de  Nancy, 
1908-09,  No.  22,  p.  83. 

t  Florentin:   Op.  cit.,  82.  J  Florentin:  Op.  cit.,  80. 


158  THE    UMBILICUS   AND    ITS    DISEASES. 

at  which  time  a  little  pus  escaped  from  the  orifice.  The  general  health  of  the  child 
was  excellent. 

At  the  umbilicus  was  a  tumor  the  size  of  a  large  horse  chestnut.  It  was  solid 
in  consistence  and  uniform  in  outline.  Its  surface  was  glistening,  brilliant,  and 
pink  in  color.  At  one  point  it  was  possible  to  introduce  a  probe  for  a  short  distance. 
On  removal  it  was  found  that,  at  the  bottom,  the  umbilical  tissue  was  very  firm  and 
much  thicker  than  usual.  At  a  point  1.5  cm.  beneath  the  cord-like  thickening  the 
operator  opened  into  a  pocket  the  size  of  a  small  mandarin  orange,  which  contained 
bloody  pus.  The  fistulous  tract  was  about  3  cm.  long.  The  tumor  was  removed, 
the  pocket  was  cureted,  and  the  wound  healed  thoroughly. 

On  histologic  examination  numerous  tubular  glands  were  found.  Outside  of 
these  there  were  muscular  tissue  and  connective  tissue.  The  condition  was  un- 
doubtedly due  to  remains  of  the  omphalomesenteric  duct. 

An  Omphalomesenteric  Duct  Open  in  its  Outer  Por- 
tion but  Closed  at  the  Intestinal  End.*  —  The  specimen  was 
removed  from  a  male  infant  ten  weeks  old.  A  small  pink  tumor  had  been  noted 
at  the  umbilicus  two  weeks  after  the  cord  came  away.  It  had  steadily  increased 
in  size.  It  was  the  size  of  a  filbert,  one  inch  long  and  half  an  inch  in  diameter. 
It  was  attached  to  the  umbilicus  by  a  narrow  pedicle.  At  the  upper  end  of  the 
tumor  was  a  small  orifice,  situated  in  the  middle  of  a  depression.  A  probe  passed 
into  the  abdomen  for  2^  inches  and  then  met  an  obstruction.  The  surface  of  the 
tumor  was  pink  and  velvety,  and  a  mucoid  fluid  constantly  flowed  from  it.  It  was 
removed  by  means  of  a  ligature  and  the  stump  treated  with  silver  nitrate. 

Microscopic  Examination.— The  mucosa  in  the  canal  and  also  on  the  surface 
was  found  to  resemble  that  of  the  intestine,  escept  that  the  villi  and  solitary  glands 
were  lacking.  The  growth  represented  a  partially  patent  Meckel's  diverticulum, 
open  almost  to  the  bowel. 

*  Wheaton,  S.  W. :  Prolapse  of  Meckel's  Diverticulum  in  an  Infant,  Forming  an  Umbilical 
Tumour.     Obst.  Trans.,  London,  1892,  xxxiv,  184. 


LITERATURE  CONSULTED  ON  PERSISTENCE  OF  THE  OUTER  PORTION  OF  THE 

OMPHALOMESENTERIC  DUCT. 

Chandelux,  A. :  Observation  pour  servir  a  l'histoire  de  l'exomphale.     Arch,  de  physiol.  norm,  et 

pathologique,  1881,  xiii,  2.  ser.,  93. 
Florentin,  P. :  Fongus  de  l'ombilic  chez  le  nouveau-ne  et  chez  l'enf ant.     These  de  Nancy,  190S-09, 

Xo.  22,  p.  83. 
Wheaton,  S.  W.:  Prolapse  of  Meckel's  Diverticulum  in  an  Infant,  Forming  an  Umbilical  Tumour. 

Obst.  Trans.,  1892,  London,  xxxiv,  184. 


CHAPTER  VIII. 
MECKEL'S  DIVERTICULUM. 

Historic  sketch. 

Hernise  of  the  tip  of  Meckel's  diverticulum. 

A  mesenteric  diverticulum. 

An  accessory  pancreas  situated  at  the  tip  of  the  diverticulum. 

Meckel's  diverticulum  in  animals. 

Intestinal  obstruction  due  to  Meckel's  diverticulum. 

Cases  of  intestinal  obstruction  caused  by  a  Meckel's  diverticulum  adherent  to  the  umbilicus. 

Intestinal  obstruction  due  to  the  tip  of  Meckel's  diverticulum  becoming  adherent  to  a  distant 
point. 

Obstruction  due  to  the  passage  of  intestine  through  a  hole  in  the  mesentery  of  Meckel's  diverticu- 
lum. 

Inversion  of  Meckel's  diverticulum  into  the  bowel. 

Treatment  of  obstruction  due  to  Meckel's  diverticulum. 


Meckel's  diver-h'cul 


Persistence  of  the  intra-abdominal  portion  of  the  omphalomesenteric  duct  pro- 
duces the  so-called  Meckel's  diverticulum  (Fig.  92).  The  subject  has  been  so  fully- 
considered  by  many  writers  that  I  shall  here  give  only  a  brief  survey,  not  attempting 
to  in  any  way  give  a  full  resume  of  the  literature.  Kern,  in  his  Inaugural  Disserta- 
tion, says  that,  according  to  Morgagni,  this 
diverticulum  was  first  observed  by  J.  H. 
Lavater,  who  in  1671  saw  a  case  of  this 
character  with  Bienaisius  in  Paris. 

Fitz  says:  "The  pouch-like  formation  of 
intestine  occasionally  seen  projecting  from 
the  lower  part  of  the  ileum  is  universally 
known  as  Meckel's  diverticulum.  Not  that 
this  distinguished  anatomist  was  its  dis- 
coverer, for  early  in  the  eighteenth  century 
Ruysch*  presented  an  admirable  illustration 
of  this  malformation.  Its  frequent  congeni- 
tal nature  was  also  recognized  before  the  time 
of  Meckel,  and  it  seems  probable  that  sug- 
gestions relative  to  its  origin  from  the  vitel- 
line duct  had  been  presented  previous  to 
the  publication  of  this  investigator. 

"We  owe  to  Meckel  not  only  the  almost 
universal  acceptance  of  his  theory  of  origin 

of  the  pouch  in  question,  but  are  also  indebted  to  him  for  calling  conspicuous  atten- 
tion to  its  importance  in  the  causation  of  serious  disease." 

In  his  "Darmanhang,"  published  by  Meckel  in  Leipzig  in  1812,  will  be  found  a 
most  careful  and  detailed  description  of  the  literature  and  of  the  anatomy  of  the 
diverticulum  which  now  bears  his  name. 

*  Thesaurus  Anatomicus,  1701. 
159 


Umb.  k: 


Fig.  92. — Meckel's  Diverticulum.  (Sche- 
matic.) 
The  diverticulum  may  pass  off  from  the  con- 
vex surface  of  the  bowel  at  right  angles  or  on  a 
slant  as  here.  In  the  latter  case,  if  the  slant  be 
very  acute,  a  valve-like  opening  may  be  the  re- 
sult. The  mucosa  of  the  small  bowel  and  of  the 
diverticulum  is  of  exactly  the  same  character. 
The  omphalomesenteric  vessels  originate  from 
the  superior  mesenteric  vessels  and  pass  over  or 
under  the  bowel  to  reach  the  duct. 


160 


THE    UMBILICUS   AND    ITS    DISEASES. 


Among  the  many  contributions  to  the  subject  there  may  be  mentioned  those  of 
King  (1843),  Struthers  (1854),  Schroeder  (1854),  Cazin  (1862),  Fitz  (1884),  Lowen- 
stein  (1894),  Richardson  (1894),  Treves  (1897),  Blanc  (1899),  and  Kelly  and  Hur- 
don  (1905). 

Fitz  says:  "There  are  certain  well-recognized  variations  in  the  seat,  size,  and 
shape  of  this  appendage  to  the  ileum.  Since  the  diverticulum  is  present  in  the 
earliest  weeks  of  fetal  life,  it  is  obvious  that  its  position  with  reference  to  the  ileo- 
cecal valve  must  change  with  the  growth  of  the  intestine. 

"The  diverticulum  is  usually  found  in  the  vicinity  of  the  valve.  In  the  new- 
born child  the  distance  between  the  two  is  about  12  inches,  while  in  the  adult  the 
diverticulum  is  found  sometimes  three  feet  above  the  ileocecal  valve.     The  limits 

within  which  it  may  be  present  are  thus  differently 
stated  by  various  authors.  Rokitansky  *  found  its  seat 
to  be  one  to  two  feet  above  the  cecum,  while  Forster  f 
extends  the  limit  to  upward  of  four  feet." 

Fitz  says  that  Major  J  described  a  diverticulum 
which  arose  from  the  jejunum.  He  also  refers  to  a  di- 
verticulum, seven  inches  in  length,  which  was  found  on 
the  border  between  the  jejunum  and  ileum.  § 

Fitz  also  says  that  Fagge||  refers  to  a  diverticulum 
which  was  54  inches  from  the  cecum  and  to  another 
which  rose  above  the  middle  of  the  ileum. 

Length.- — ■  Fitz  says  that,  although  the  diver- 
ticulum is  commonly  found  to  be  less  than  4  inches  long, 
Rokitansky  assigns  to  it  a  maximum  length  of  10  inches. 
One  of  the  best  descriptions  of  Meckel's  diverticulum  is 
to  be  found  in  Kelly  and  Hurdon's  "Appendicitis  and 
Diseases  of  the  Vermiform  Appendix"  (p.  594). 

This  diverticulum  projects  from  the  convex  surface 
of  the  intestine,  and  may  be  short  or  long;  sometimes 
it  is  free,  at  other  times  attached  to  the  umbilicus  by  a 
fibrous  cord.  Occasionally  it  extends  in  its  continuity 
to  the  umbilicus  (Fig.  93),  and  where  it  is  attached  to 
the  intestine  the  two  are  often  of  the  same  diameter. 
The  outer  portion  of  the  diverticulum  may  be  of  the 
same  caliber  and  then  end  in  a  rounded  extremity 
similar  to  the  bottom  of  a  test-tube ;  or  the  duct  may 
gradually  taper  off  toward  its  extremity. 
The  walls  of  the  diverticulum  are  continuous  with  those  of  the  intestine,  and 
are  .similar  to  them  both  macroscopically  and  microscopically. 

The  diverticulum  may  or  may  not  have  a  mesentery.  Where  none  exists,  the 
blood  supply  comes  from  the  intestine.  In  those  cases  in  which  a  mesentery  is 
found,  it  naturally  is  on  one  side,  the  other  being  perfectly  smooth.     The  blood- 

*  Rokitansky:  Lehrbuch  der  path.  Anat,,  1861,  3.  Aufl.,  182. 

t  Forster:  Handbuch  der  path.  Anat.,  1863,  2.  Aufl.,  97. 

t  Major:  The  Lancet,  1839-40,  i,  362. 

§  Aerztlichcr  Ber.  aus  dem  K.  K.  Allg.  Krankenhause  zu  Wien,  1862,  221. 

||  Fagge:   Guy's  Hospital  Reports,  3.  series,  1869,  xiv,  359. 


Fig.  93. — Meckel's  Divertic- 
ulum Attached  to  the  Ab- 
dominal Wall  at  the  Um- 
bilicus. (After  Beck.) 
The  picture  shows  the  inner 
surface  of  the  anterior  abdominal 
wall,  to  which  Meckel's  divertic- 
ulum has  become  attached,  a  is 
the  small  bowel;  B,  the  inner  sur- 
face of  the  abdominal  wall;  C,  the 
umbilicus.  In  the  lower  part  of 
the  picture  is  seen  the  bladder. 
Passing  upward  from  the  ver- 
tex of  this  is  the  urachus.  E,  E, 
are  the  umbilical  arteries  seen  on 
either  side.  Passing  outward  from 
the  small  bowel  to  the  umbilicus 
is  Meckel's  diverticulum.  G,  G, 
represent  the  omphalomesenteric 
arteries;  H,  the  omphalomesen- 
teric vein. 


MECKEL'S    DIVERTICULUM. 


161 


vessels  come  from  the  mesentery  of  the  small  bowel,  pass  over  the  ileum,  and  then 
spread  out  in  a  plexus  over  the  diverticulum.  Where  the  diverticulum  is  adherent 
to  the  umbilicus,  its  peritoneum  may  be  continuous  with  that  of  the  abdominal  wall, 
and  small  vessels  from  the  abdominal  wall  may  extend  over  to  the  duct  (Fig.  91). 

If  the  diverticulum  be  free  and  the  mesentery  short,  the  former  may  be  drawn 
down  toward  the  bowel  on  one  side,  so  that  this  appendage  presents  a  curved  or 
snout-like  appearance.  Lowenstein  says  that  Riefkohl  reported  the  cases  of  three 
children  of  one  mother,  each  of  whom  had  a  Meckel's  diverticulum. 

The  fibrous  cords  occasionally  found  extending  from  the  tip  of  the  diverticulum 
to  the  umbilicus  are  usually  remnants  of  the  omphalomesenteric  vessels.  These 
are  referred  to  at  length  in  Chapter  XIV. 

H  e  r  n  i  se  of  the  tip  of  the  diverticulum  have  been  referred  to  by  King,  Fitz, 
Kelly  and  Hurdon,  and  others. 


Fig.  94. — An  Abnormally  Large  Meckel's  Diverticulum.    (After 

Richardson.) 

The  Meckel's  diverticulum  here  is  practically  as  large  as  the  small 

bowel.     It  is  attached  directly  to  the  umbilicus. 


Fig.  95. — A  Meckel's  Diverticulum  with 

A       LOBULATED      EXTREMITY.         (After 

King.)      (Prep.   1818,   Guy's   Hospital 

Museum.) 

Meckel's  diverticulum  has  a  diameter 
nearly  as  large  as  the  small  bowel  from 
which  it  arises.  The  diverticulum  ends  in 
several  round  hernial  projections. 


King,  in  1843,  referred  to  a  very  interesting  case  of  this  character  (Fig.  95). 
The  tip  of  the  diverticulum  was  free  and  ended  in  seven  or  eight  rounded  cystic 
dilatations. 

Fitz,  in  the  examination  of  the  Meckel's  diverticula  in  the  Harvard  Medical 
School  (Improvement  Collection,  No.  1033),  found  a  chverticulum  with  two  rounded 
bulgings  at  its  free  end.     These  were  large  enough  to  suggest  an  incipient  bifurcation. 

Fitz  quotes  Hyrtl*  as  saying  that  branched  diverticula  are  extremely  rare.  In 
making  an  autopsy  on  a  hemicephalic  monster,  Hyrtl  found  a  diverticulum  an  inch 
long.     This  toward  the  end  was  divided  into  five  parts. 

Kelly  and  Hurdonf  show  a  long  diverticulum  with  several  small,  cyst-like  dila- 
tations or  hernia?  near  its  tip  (Fig.  96). 

The  opening  of  the  diverticulum  into  the  bowel  may  be  large  and  oval  or  round; 

*  Hyrtl:   Handbuch  der  topographischen  Anatomie,  1860,  i,  642. 

t  Kelly  and  Hurdon:  The  Vermiform  Appendix  and  its  Diseases,  Fig.  314,  p.  598. 

12 


162 


THE    UMBILICUS   AND    ITS    DISEASES. 


occasionally  it  is  valve-like.  This  last  condition  occurs  where  the  diverticulum 
leaves  the  bowel  tangentially. 

Cazin,  in  1862,  referred  to  a  case  in  which  Meckel's  diverticulum  opened  into 
the  intestine  by  two  orifices,  separated  by  a  bridge.  The  superior  one  was  sur- 
rounded by  a  circular  valve. 

A  Mesenteric  Diverticulum.- — ■  Although  diverticula  usually 
spring  from  the  convexity  of  the  bowel,  in  rare  instances  they  are  noted  at  its  mes- 
enteric attachment. 

King,  in  1843,  referred  to  a  specimen  in  Guy's  Hospital  Museum  (Fig.  97). 
The  diverticulum  was  very  short.     It  sprang  from  the  mesenteric  border  of  the 


Nonvascular  serous  fold. 

between    ileum    and 
diverticulum 


W\tuf.     P"fooUf.     ft*    g'n . 


Fig.  96. — A  Meckel's  Diverticulum  with  Hernial  Protrusions  from  its  Surface.     (After  Kelly  and  Hurdon.) 


small  bowel,  and  was  adherent  to  the  mesentery.  This  subject  is  considered  at 
length  in  the  chapter  dealing  with  Intestinal  Cysts. 

An  Accessory  Pancreas  Situated  at  the  Tip  of  the 
Diverticulum.  —  Bize,  in  1904,  gave  an  interesting  account  of  a  case  in 
which  an  accessory  pancreas  was  found  at  the  tip  of  a  Meckel's  diverticulum  (Fig. 
98).  He  gives  both  macroscopic  and  microscopic  pictures  of  the  case,  and  draws 
attention  to  the  fact  that  cystic  tumors  may  possibly  develop  from  such  accessory 
pancreases. 

Deve,  in  1906,  records  a  case  in  which  Meckel's  diverticulum  was  7  cm.  long.  At 
its  extremity  was  a  thickening  the  size  of  a  small  bean.    It  was  an  accessory  pancreas. 

Denuce,  in  1908,  referred  to  a  case  reported  by  Albrecht.  In  this  case  Meckel's 
diverticulum  had  at  its  extremity  a  yellowish  nodule  the  size  of  a  pea.  This  nodule, 
on  histologic  examination,  was  found  to  consist  of  pancreatic  tissue. 


MECKEL  S    DIVERTICULUM. 


163 


It  will  be  interesting  to  see  if,  as  Bize  suggests,  pancreatic  cysts  may  possibly 
develop  in  the  tip  of  the  diverticulum.  If  such  a  condition  were  probable,  one  would 
naturally  expect  the  literature  to  contain  records  of  a  few  such  conditions,  but  I 
have  not  been  able  to  locate  a  cyst  of  Meckel's  diverticulum  that  in  any  way  sug- 
gested a  pancreatic  origin. 

Meckel's  Diverticulum  in  Animals  . — Tillmanns  says  that  the 
observations  of  Cazin  have  shown  that  true  di- 
verticula, having  no    connection  with  the  ab- 
dominal wall,  are  regularly  present  in  the  water- 
hen,  snipe,  and  swan. 

Fitz  quotes  Morgagni  as  saying  that  he  had 
observed  the  diverticulum  on  more  than  one 
occasion  in  geese. 

Cazin,  in  his  thesis  on  Intestinal  Diverticula, 
published  in  1862,  reported  an  observation  of 
Guobaux.  Guobaux,  on  January  15, 1855,  made 
an  autopsy  on  a  sheep.  In  the  lower  portion  of 
the  small  intestine  was  a  diverticulum  9  cm.  in 


Fig.  97. — A  Short  Meckel's  Diverticulum  Springing  from  the 
Mesenteric  Attachment.  (After  King.)  (Prep.  1819", 
Guy's  Hospital  Museum.) 


Fig.  98. — An  Accessort  Pancreas  in 
the  Tip  op  Meckel's  Diverticulum. 
(After  Bize.) 

Meckel's  diverticulum  (.4)  was  dilated, 
and  at  its  tip  was  a  nodule  the  size  of  a  small 
nut  (B) .  This  nodule  on  histologic  examina- 
tion was  found  to  consist  of  pancreatic  tissue. 


length,  and  of  a  caliber  equal  to  that  of  the  small  bowel.  It  had  the  same  structure 
as  the  intestine.  On  examining  this  canal  he  found  that  a  Peyer  patch  had  ex- 
tended a  short  distance  into  the  interior  of  the  diverticulum.  Guobaux  also 
referred  to  diverticula  occurring;  in  birds. 


INTESTINAL  OBSTRUCTION  DUE  TO  MECKEL'S  DIVERTICULUM. 

As  the  reader  is  thoroughly  familiar  with  obstructions  of  this  character,  and  as 
the  literature  on  this  subject  is  so  large,  I  shall  not  attempt  to  cover  the  subject, 
but  shall  merely  give  a  few  examples  of  some  of  the  manifold  ways  in  which  a 
Meckel's  diverticulum  may  occasion  obstruction. 

A  Case  of  Intestinal  Obstruction  in  which  Meckel's 
Diverticulum   was   Free.  —  The  following  case  gives  a  graphic  picture 


164 


THE    UMBILICUS    AND    ITS    DISEASES. 


of  what  a  free  Meckel's  diverticulum  may  do.  The  specimen  was  kindly  placed 
at  my  disposal  by  Dr.  Joseph  C.  Bloodgood:  August  L.,  aged  forty-two,  came  under 
the  care  of  Dr.  H.  Jones,  of  Irvington,  Mel.,  early  on  the  morning  of  June  9,  1914. 


Fig.  99. — Meckel's  Diverticulum  Completely  Tying  off  a  Loop  of  Small  Bowel. 
This  specimen  was  removed  by  Dr.  George  A.  Stewart  at  St.  Agnes'  Hospital,  Baltimore,  June  9,  1914.     The 
arrows  indicate  the  cut  ends  of  the  bowel.    The  intestinal  loop  is  greatly  distended.    The  pear-shaped  cyst  is  a  Meckel's 
diverticulum.     Its  extremity  is  perfectly  free,  and  on  its  upper  surface  its  blood-vessels  stand  out  prominently.     It 
ha-  in  some  manner  become  tied  around  the  gut.      (For  the  key,  see  Fig.  100.) 


At  1  a.  m.  he  had  nausea  and  vomiting,  and  shortly  afterward  abdominal  pain. 
His  bowels  had  moved  once,  but  later  were  obstinately  constipated.  Twelve 
hours  later  he  had  tenderness  all  over  the  abdomen. 

Operation  (at  St.  Agnes'  Hospital). — Fifteen  hours  after  the  symptoms  de- 


MECKEL  S    DIVERTICULUM. 


165 


veloped  Dr.  George  A.  Stewart  opened  the  abdomen  and  found  a  large  loop  of  bowel 
much  distended  and  very  dark.  Its  mesentery  appeared  to  be  gangrenous.  The 
bowel  was  so  knotted  at  one  point  that  no  attempt  was  made  to  unravel  it,  and 
the  entire  area  was  removed.  The  ends  were  closed,  and  a  lateral  anastomosis 
was  made.  The  abdomen  was 
closed  without  drainage.  The 
patient  made  a  good  recov- 
ery. 

Dr.  Bloodgood,  in  his  de- 
scription, says:  "The  speci- 
men consists  of  about  18 
inches  of  small  gut,  dark 
brown  in  color,  and  of  the 
hardness  of  paper.  At  one 
end  there  is  a  peculiar  knot, 
which  was  the  cause  of  the 
volvulus  and  thrombosis  (Fig. 
99).  From  the  picture  it  is 
seen  that  the  bowel  is  mark- 
edly distended.  The  ends  of 
the  resected  gut  are  indicated 
by  the  arrows.  The  cystic 
mass  (M)  is  the  greatly  di- 
lated Meckel's  diverticulum. 
It  is  perfectly  smooth,  and  on 
its  upper  surface  are  its  mesen- 
teric vessels. ' '  From  the  pic- 
ture it  is  very  difficult  to  say 
just  how  the  obstruction  oc- 
curred. Fig.  100,  made  by 
Max  Brodel,  gives  the  key  to 
the  situation.  A  loop  of 
bowel  had  become  twisted, 
Meckel's  diverticulum  had 
dropped  over  this,  encircling 
it  completely,  and  the  tip  had 

then  passed  through  the  space  between  its  own  base  and  the  small  bowel, 
result  of  the  obstruction  all  the  affected  parts  soon  swelled  up. 

Early  operation  afforded  the  only  hope  of  saving  such  a  patient. 


Fig.  100. — A  Diverticulum  Tyixg  off  a  Loop  of  Small  Bowel. 
This  indicates  the  manner  in  which  the  obstruction  occurred  (ef. 
Fig.  99) .  Meckel's  diverticulum  has  dropped  over  a  loop  of  bowel  which 
has  been  partly  twisted.  After  passing  under  the  loop  it  curves  upward 
and  passes  through  the  space  between  the  base  of  the  diverticulum  and 
the  adjacent  small  bowel.  With  the  consequent  distention  of  the  con- 
stricted bowel,  complete  obstruction  has  resulted. 


As  a 


CASES  OF  INTESTINAL  OBSTRUCTION  CAUSED  BY  A  MECKEL'S  DIVERTICULUM 
ADHERENT  TO  THE  UMBILICUS. 

Intestinal  obstruction  is  more  likely  to  occur  when  the  diverticulum  extends  to 
and  is  fixed  to  the  umbilicus,  or  when  it  is  attached  to  the  umbilicus  by  a  fibrous  cord. 

Strangulation  of  Meckel's  Diverticulum  Caused  by 
Volvulus    of    the    Ileum.*  —  Elliot's  patient  was   a  man,  aged  thirty, 

*  Elliot,  J.  W.:  Trans.  Amer.  Surg.  Assoc,  1894,  xii,  217. 


166 


THE    UMBILICUS    AND    ITS    DISEASES. 


who  was  admitted  to  the  Massachusetts  General  Hospital.     He  had  been  sick  for 

four  days.     He  gave  a  history  of   vomiting,   chills,   and   abdominal  pain.     On 

admission  his  temperature  was  103.6°  F. ;  pulse,  160. 
The  abdomen  was  distended  and  exceedingly  tender, 
especially  to  the  right  of  and  below  the  umbilicus ;  there 
was  free  fluid  in  the  abdominal  cavity. 

Operation. — When  the  abdomen  was  opened,  there 
was  an  escape  of  turbid  fluid.  The  appendix  was  normal. 
The  mass  encountered  looked  like  a  large,  dilated,  and 
gangrenous  knuckle  of  intestine,  but  without  a  mesen- 
tery. It  sprang  from  the  lower  part  of  the  convex  sur- 
face of  the  ileum  and  was  tightly  twisted  at  its  point  of 
attachment  to  the  bowel.  (See  Fig.  101.)  It  extended 
upward  into  a  dense  mass  of  adhesions,  and  was  found 
to  be  attached  to  the  under  surface  of  the  umbilicus. 
It  was  a  strangulated  and  gangrenous  Meckel's  diver- 
ticulum, 7  inches  long,  and  about  the  same  size  as  the 
ileum.  During  dissection  it  ruptured.  The  ileum  at 
this  point  was  found  to  be  twisted  on  itself  and  held  in 
position  by  adhesions.  The  gut  was  not  wholly  ob- 
structed by  the  twist.  The  diverticulum,  having  its 
outer  end  fixed  at  the  umbilicus,  was  twisted  and 
strangulated  at  its  base  by  the  turning  over  of  this  coil 
of  ileum.  The  gangrene  of  the  diverticulum  was  most 
intense  near  the  ileum,  the  end  at  the  umbilicus  being 
only  moderately  inflamed.  The  patient  died  on  the 
second  day. 

Fatal  Intestinal  Obstruction  Due 
to  Remains  of  the  Omphalomesen- 
teric Duct.*  —  Mrs.  M.  C,  aged  twenty-four, 
admitted  to  St.  Francis'  Hospital,  Pittsburgh,  June  6, 
1906.  The  patient  had  always  been  healthy  until  the 
onset  of  the  present  illness.  Three  days  previous  to 
admission  she  was  seized  with  sudden  severe  pain 
in  the  abdomen.  This  was  followed  by  vomiting. 
There  was  a  slight  elevation  of  temperature;  the  pulse 
was  rapid. 

The  diagnosis  of  intestinal  obstruction  was  made, 
and  immediate  operation  advised.  When  the  abdomen 
was  opened,  a  gangrenous  loop  of  ileum  was  found. 
This  was  twisted  twice  about  a  narrow  band  which  was 
attached  at  one  end  to  the  umbilical  site;  at  the  other 
end,  to  the  convex  surface  of  the  ileum,  about  six  inches 
from  the  cecum.  A  resection  of  the  bowel  was  made, 
but  the  patient   died  three   days  later  of  peritonitis. 

Examination  of  the  section  of  the  band  which  was  removed  showed  clearly  that 

it  was  the  obliterated  remnant  of  the  vitelline  duct. 

*  Muggins,  R.  R. :   Personal  communication. 


Fig.  101. — Strangulation  op 
Meckel's  Diverticulum 
Causing  Volvulus  op  the 
Ileum.  (Redrawn  after 
Elliot.) 

The  specimen  was  from  a 
man  aged  thirty  who  had  signs 
of  intestinal  obstruction.  The 
abdomen  contained  turbid  fluid. 
In  the  incision  a  mass  presented 
which  looked  like  a  large,  dilated 
gangrenous  loop  of  intestine,  but 
had  no  mesentery.  It  sprang 
from  the  lower  part  of  the  con- 
vex surface  of  the  ileum,  and  was 
slightly  twisted  at  its  point  of 
attachment  to  the  bowel.  It 
extended  upward  into  a  dense 
mass  of  adhesions,  and  was 
found  to  be  attached  to  the  un- 
der surface  of  the  umbilicus.  It 
was  a  strangulated  and  gangren- 
ous  Meckel's  diverticulum.  It 
was  about  seven  inches  long,  and 
had  about  the  same  diameter  as 
the  ileum.  The  small  bowel  at 
thia  point  was  twisted  on  itself 
and  held  in  position  by  adhe- 
sions. The  gut  was  partially 
obstructed  at  the  twist.  The 
patient  died  on  the  second  day 
after  operation. 


Meckel's  diverticulum.  167 

Ileus  Caused  by  Persistence  of  the  Omphalomesen- 
teric Duct.*  —  The  patient,  a  man  nearly  twenty  years  of  age,  had  always 
been  strong  and  hearty.  He  was  suddenly  seized  with  vomiting  and  pain  in  the 
umbilical  region.  The  vomiting  was  frequent,  and  two  days  later  assumed  a  fecal 
character.     The  abdomen,  particularly  in  the  lower  half,  was  much  distended. 

Operation. — When  the  abdomen  was  opened,  a  part  of  the  bowel  was  found 
distended;  the  rest  was  contracted.  One  loop  of  bowel  was  green  and  gangrenous. 
The  gangrene  had  been  caused  by  a  half-turn  made  by  a  cord  the  size  of  the  little 
finger  passing  from  the  umbilicus.  This  cord  was  inserted  in  the  gangrenous  loop. 
It  was  an  omphalomesenteric  duct.  The  gangrenous  loop  of  small  bowel  was  1.1 
meters  long,  and  reached  to  within  7  cm.  of  the  ileocecal  valve.  A  resection  was 
made  but  the  patient  died  almost  immediately. 

Fatal  Intestinal  Obstruction  in  Consequence  of  a 
Twist  in  the  Mesentery  and  the  Falling  of  Some  Folds 
of  Intestine  over  a  True  Diverticulum. f  —  The  patient,  a 
strong,  robust  boy,  was  seized  with  a  violent  pain  in  the  abdomen  after  drinking  a 
cup  of  hot  coffee.  He  had  no  movement  of  the  bowels  for  six  days.  General 
peritonitis  developed,  and  he  died  on  the  ninth  day. 

Autopsy. — On  section,  general  peritonitis  was  found.  The  mesentery  of  some 
loops  of  the  small  bowel  was  twisted  on  itself.  The  intestines  were  deeply  injected 
and  quite  black.  Loops  of  intestine  had  fallen  over  a  diverticulum,  which  extended 
from  the  small  gut  to  the  linea  alba,  about  one  inch  below  the  umbilicus.  The 
diverticulum  was  5  inches  long  and  34  inches  distant  from  the  cecum. 

Strangulation  of  Intestine  by  Diverticulum  Ilei.|  — 
Eliza  W.,  aged  ten,  was  admitted  with  symptoms  of  strangulated  bowel.  Peri- 
tonitis developed,  and  she  died  in  a  few  hours.  The  symptoms  had  begun  ten  days 
before  death,  with  an  attack  of  sickness  attributed  to  the  eating  of  some  indigestible 
fruit. 

Autopsy. — On  section,  an  acute  peritonitis  was  found.  When  the  abdominal 
wall  was  lifted  up,  a  band  was  seen  passing  from  the  umbilicus  to  the  lower  part  of 
the  ileum,  to  which  it  was  attached.  The  portion  of  the  gut  above  was  much  dis- 
tended; the  part  below  was  contracted.  The  constricting  band  was  found  to  be  a 
diverticulum  of  the  ileum  which  had  become  obliterated  at  the  umbilicus.  At  its 
origin  it  was  of  the  same  caliber  as  the  contracted  portion  of  the  ileum  below  it. 

"The  only  practical  consideration  arising  from  such  a  case  is  to  remember  that, 
in  an  exploratory  operation  in  a  case  of  obstruction,  a  cord  passing  to  the  umbilicus 
is  very  likely  to  be  a  diverticulum  of  intestine." 

Wilks  says  that,  in  the  Guy's  Hospital  Museum,  there  are  four  specimens  of 
this  malformation  causing  obstruction  of  the  intestine.  In  one  case  the  patient 
had  reached  forty-three  years  of  age.  In  another,  a  child,  the  patient  had  previ- 
ously undergone  a  successful  plastic  operation  for  a  fecal  discharge  from  the  umbili- 
cus. 

*  Jordan,  Max:  Ueber  Ileus  verursacht  clurch  den  persistirenden  Ductus  omphalo-mesa- 
raicus.     Berlin,  klin.  Wochenschr.,  1896,  xxxiii,  25. 

t  Ward,  Nathaniel:  Trans.  Path.  Soc.  London,  1856,  vii,  205. 
%  Wilks,  Samuel:   Trans.  Path.  Soc.  London,  1865,  xvi,  126. 


168  THE    UMBILICUS    AND    ITS    DISEASES. 

INTESTINAL  OBSTRUCTION  DUE  TO  THE  TIP  OF  MECKEL'S  DIVERTICULUM 
BECOMING  ADHERENT  TO  A  DISTANT  POINT. 

The  following  case  reported  by  Sheen  is  a  very  good  example  of  this  group  of 
cases : 

Fatal  Intestinal  Obstruction  Due  to  Meckel's  Di- 
verticulum.* —  Case  2  .  —  A.  L.  W.,  male,  aged  forty-one.  Admitted 
to  the  Cardiff  Infirmary,  November  7,  1899. 

"  History. — Loss  of  flesh  for  one  year.  Present  illness  began  with  an  attack  of 
abdominal  pain  after  supper  nine  days  ago.  Since  then  absolute  constipation  and 
constant  vomiting,  which  has  been  fecal  for  the  last  six  days.  Has  had  two  enemata 
without  effect.     Abdominal  pain  and  latterly  hiccough  have  been  constant. 

"Present  Condition. — The  man  looks  very  ill,  with  cold  extremities;  pulse,  72, 
feeble;  temperature,  97°  F.  Has  vomited  a  little  brown  fluid  matter,  smelling 
fecal.  Abdomen  moderately  distended,  flanks  and  hypochondriac  region  somewhat 
flattened;  some  dulness  above  pubes;  remainder  resonant,  peculiar  hollow,  high- 
pitched  note  over  position  of  sigmoid  flexure ;  no  visible  peristalsis ;  splashing  sounds 
on  manipulation;  rectal  examination  negative;  pain  referred  to  umbilicus. 

' '  The  patient  was  given  ether  immediately,  and  the  abdomen  opened  in  the  left 
iliac  region.  The  colon  was  found  empty;  some  distended  coils  of  small  intestine 
presented  themselves,  and  the  hand  could  feel  something  like  a  band  on  the  right 
side,  and  apparently  near  the  pelvic  brim.  The  closure  of  the  wound  was  com- 
menced with  a  view  to  opening  in  the  middle  line,  when,  somewhat  suddenly,  the 
patient,  whose  condition  was  extremely  serious  throughout,  collapsed  and  died. 
The  trachea  was  opened,  and  various  measures  resorted  to  to  restore  animation, 
but  without  effect. 

"Postmortem  (Twelve  Hours  After  Death). — Abdomen  only  opened  through  a 
crucial  incision.  No  peritonitis.  Small  intestine  distended  and  injected.  With- 
out disturbance,  the  seat  of  obstruction  was  at  once  seen  in  the  form  of  a  diverticu- 
lum of  the  bowel  passing  downward  and  outward  from  the  median  line,  at  a  point 
about  opposite  to  the  third  lumbar  vertebra,  toward  the  pelvic  brim.  On  examina- 
tion the  diverticulum,  which  was  devoid  of  a  mesentery,  was  found  to  be  about  four 
inches  long,  bulbous  at  its  commencement,  then  narrowing  suddenly,  but  patent  to 
its  extremity.  It  sprang  from  the  posterior  aspect  of  the  ileum,  about  two  feet 
above  the  ileocecal  valve,  curved  forward  and  inward  round  the  bowel  from  which 
it  came,  and  passed  downward  and  inward,  to  be  attached  by  its  apex  to  the  small 
intestine  again,  about  five  inches  from  the  ileocecal  valve.  The  obstruction  of  the 
ileum  took  place  at  the  point  of  attachment  of  the  apex  of  the  diverticulum,  which 
attachment  was  made  by  a  few  short,  firm  adhesions.  The  bowel  was  very  near 
perforation  at  this  point.  The  gut  was  also  pressed  upon  somewhat  at  two  points 
above  the  actual  seat  of  obstruction:  (1)  Where  the  diverticulum  wrapped  itself 
around  the  ileum  at  its  point  of  origin;  (2)  where  a  loop  of  bowel  passed  under  the 
diverticulum.  It  was  evident  that  the  more  distended  the  bowel  became,  the  more 
would  the  diverticulum  pull  upon  and  kink  its  point  of  attachment." 

Sheen,  William:   Some  Surgical  Aspects  of  Meckel's  Diverticulum.     Bristol  Medico-Chir. 
Jour.,   1901.  xix,  :ni). 


Meckel's  diverticulum.  169 


OBSTRUCTION  DUE  TO  THE  PASSAGE  OF  INTESTINE  THROUGH  A  HOLE  IN  THE 
MESENTERY  OF  MECKEL'S  DIVERTICULUM. 

I  have  not  found  the  record  of  a  similar  case  in  the  literature.  The  mesentery 
of  the  diverticulum,  as  a  rule,  is  very  slender  and  narrow,  and  even  if  a  hole  existed, 
the  bowel  would  tend  to  pass  not  through  but  over  it. 

Umbilical  Polyp;  Intestinal  Obstruction  Due  to 
Hernia  through  the  Mesentery  of  Meckel's  Divertic- 
ulum. Death.*  —  "E.  T.  L.,  male,  aged  one  year,  nine  months,  admitted 
to  the  Cardiff  Infirmary  April  22,  1897. 

"History. — Swelling  at  the  navel  since  birth.  The  confinement  was  not  at- 
tended by  a  doctor.  The  swelling  has  always  been  the  same  size.  About  a  half- 
pint  of  glairy  fluid  comes  from  it  in  twenty-four  hours,  staining  and  stiffening 
the  linen.     The  general  health  has  always  been  good. 

"  Present  Condition. — A  healthy,  well-nourished  child.  Attached  to  the  center 
of  the  navel  is  a  bright-red,  bluntly  lobulated,  pedunculated  tumor  the  size  of  a 
grape,  with  skin  reaching  only  to  its  margin.  The  surface  resembles  intestinal 
mucous  membrane  and  exudes  a  viscid  fluid  of  alkaline  reaction.  In  the  center  is  a 
channel  one  inch  deep.  Through  the  parietes  a  cord  the  thickness  of  a  cedar 
pencil  can  be  felt  passing  backward  for  about  13^2  inches.  Urination  and  defeca- 
tion are  normal. 

"After  admission  the  fluid  was  collected  as  far  as  possible  in  a  small  glass  vase 
strapped  to  the  child's  abdomen.  The  total  amount  in  twenty-four  hours  was  10 
to  15  c.c. ;  on  two  occasions,  22  c.c. ;  sometimes  there  were  only  5  c.c,  but  then  some 
was  lost.  It  was  a  colorless,  viscid  fluid,  and  could  be  poured  from  vessel  to  vessel 
like  a  thin  jelly;  it  was  alkaline  in  reaction  and  contained  a  little  albumin.  It  had 
no  digestive  action  on  fibrin  or  starch.  So  far  as  our  examination  went,  therefore, 
it  resembled  succus  entericus.  On  July  31st  the  tumor  was  removed  with  scissors 
and  the  base  cauterized,  the  procedure  being  quite  a  slight  one.  The  child  vomited 
continuously  after  the  anesthetic.  On  August  3d  a  simple  enema  was  given,  and 
the  bowels  moved  twice;  on  the  following  days  the  child  was  fretful  and  became 
thinner;  the  milk  was  peptonized,  but  the  vomiting  continued,  the  vomitus  con- 
sisting of  undigested  milk;  the  abdomen  was  distended  and  tender.  The  child 
grew  worse.  On  August  7th  a  blood-streaked  motion  is  stated  to  have  been  passed 
after  an  enema,  but  it  was  not  saved  by  the  nurse.  Nutrient  enemata  were  given 
toward  the  end,  but  the  child  died  at  5  p.  m.  on  August  7th,  one  week  after  operation. 
The  cause  of  death  was  thought  to  be  peritonitis. 

"August  8th,  Postmortem. — No  peritonitis.  Death  was  found  to  be  due  to 
intestinal  strangulation.  The  parts  involved  were  removed  for  separate  examina- 
tion. In  the  specimen  removed  were  the  lower  part  of  the  small  intestine,  cecum, 
appendix,  and  a  small  piece  of  ascending  colon.  Connected  with  the  small  intestine 
was  a  Meckel's  diverticulum,  patent  to  within  an  inch  of  the  umbilicus,  to  which 
it  was  attached  by  a  solid  cord  (Fig.  102).  The  skin  around  the  umbilicus  was 
removed  by  an  elliptic  incision. 

"  On  dissection  the  following  points  were  made  out :  (1)  The  bowel  is  strangulated 
by  being  herniated  through  a  hole  (A)  in  the  mesentery  of  the  diverticulum  ilei. 
(2)  The  constricted  bowel  is  25  inches  in  length.      (3 J  Practically  all  the  bowel 

*  Sheen,  W.:  Op.  cit. 


170 


THE    UMBILICUS    AND    ITS    DISEASES. 


between  the  origin  of  the  diverticulum  and  the  ileocecal  valve  is  strangulated.  (4) 
The  strength  of  the  constricting  cord  of  mesentery  is  largely  due  to  a  vessel  travers- 
ing it.  (5)  The  bowel  is  twisted  within  the  ring  and  near  perforation  at  its  proximal 
end.  (6)  The  diverticulum  is  bulbous  in  shape,  and  its  lumen  is  much  narrowed 
where  it  joins  the  intestine. 

"  Fig.  [102]  shows  the  condition,  the  strangulated  loop  represented  as  being 
turned  out  of  the  constricting  ring  (A).     The  polypus  is  shown.     The  position  of 

the  appendix  was  interesting.  It  lay  against 
the  diverticulum,  with  its  apex  pointing  to- 
ward the  liver. 

"  Microscopic  examination  of  the  polypus 
showed  a  connective-tissue  basis,  with  a 
layer  of  intestinal  glands — exactly  like  Lieb- 
erkiihn's  follicles.  In  places  the  intestinal 
glands  were  proliferating,  so  as  to  produce 
a  mass  resembling  an  ordinary  intestinal 
adenoma. 

"Clinically  disappointing,  this  case  is  of 
great  interest  pathologically.  The  writer 
has  been  able  to  find  no  other  record  of  a 
case  of  strangulation  through  the  mesentery 
of  a  Meckel's  diverticulum." 


Fig.  102. — Fatal  Intestinal  Obstruction  Due 
to  the  Passage  of  the  Bowel  through  a 
Hole  in  the  Mesentery  of  a  Meckel's 
Diverticulum.  (After  Sheen.) 
Attached  to  the  umbilical  depression  was  a 
bright  red,  bluntly  lobulated,  pedunculated  tumor 
the  size  of  a  grape.  Its  surface  was  covered  with 
mucosa.  In  the  center  was  a  channel  one  inch 
deep,  and  through  the  abdominal  walls  a  cord  the 
size  of  a  lead-pencil  could  be  felt  extending  back- 
ward into  the  abdomen.  The  child  developed  in- 
testinal obstruction  and  died.  At  autopsy  25 
inches  of  small  bowel  were  found  to  have  passed 
through  the  hole  (A)  in  the  mesentery  of  Mec- 
kel's diverticulum.  Practically  all  the  bowel  be- 
tween the  diverticulum  and  the  ileocecal  valve 
had  become  strangulated.  The  strength  of  the 
constricting  cord  of  mesentery  was  due  largely 
to  a  vessel  traversing  it.  Meckel's  diverticulum 
was  bulbous  in  shape  and  much  narrowed  where 
it  joined  the  small  bowel. 


INVERSION   OF   MECKEL'S   DIVERTICULUM 
INTO  THE  BOWEL. 

The  following  case,  recorded  by  Ktittner, 
is  a  very  rare  one.  The  diverticulum  had 
turned  inside  out,  just  as  when  one  inverts 
the  finger  of  a  glove.  It  projected  into  the 
bowel  and  had  caused  obstruction  and  sub- 
sequent intestinal  perforation. 

Ileus  Due  to  Intussuscep- 
tion of  Meckel's  Divertic- 
ulum.* —  This  case  was  observed  by 
Bruns.  A  woman,  forty-nine  years  of  age, 
had  always  been  well  up  to  eight  weeks  pre- 
viously, when  she  suddenly  showed  signs  of  intestinal  obstruction.  There  was  fecal 
vomiting  for  five  days.  The  patient  then  improved,  but  did  not  get  perfectly  well. 
Three  days  before  her  admission  the  symptoms  returned  and  rapidly  grew  worse. 
At  operation  the  peritoneum  was  found  to  be  markedly  injected.  The  intestines 
were  covered  with  fibrin  and  were  lightly  adherent,  and  in  the  pelvis  was  a  thin, 
odorless  fluid.  Part  of  the  small  intestine  was  dilated,  and  the  rest  collapsed.  No 
obstruction  could  be  found,  and  there  was  no  evidence  of  perforation.  The  fluid  was 
wiped  out,  and  an  anastomosis  made  between  the  dilated  and  collapsed  bowel.  A 
drain  was  left  in  the  lower  angle  of  the  wound.     The  patient  died  three  days  later. 

*  Kuttner,  H.:    Ileus  dureh  Intussusception  eines  MeckeFschen  Divertikels.     Beitrage  zur 
klin.  Chir.,  1898,  xxi,  289. 


MECKEL  S    DIVERTICULUM. 


171 


Autopsy. — The  peritonitis  had  progressed.  About  90  cm.  from  the  beginning 
of  the  jejunum  was  an  area  of  thickening  4  cm.  long.  Here  there  was  a  polyp-like 
structure  7  cm.  long,  having  at  its  base  a  breadth  of  a  thumb.  It  was  a  Meckel's 
diverticulum  that  had  turned  inside  out  and  projected  into  the  bowel  (Fig.  103). 
The  intestinal  lumen  at  this  point  was  somewhat  narrowed.  The  portion  of  the 
bowel  at  the  point  of  the  insertion  of  the  diverticulum  had  also  become  drawn  into 
the  lumen.  Near  the  base  of  the  diverticulum  was  a  gangrenous  spot  and  a  small 
perforation. 

Kiittner  then  gives  the  report  of  seven  other  cas.es  which  he  had  collected 
from  the  literature.     These  were  those  of  Maroni,   Ewald,   St.   Bartholomew's 
Hospital,  Adams,  and  three  recorded  by 
Heller. 


TREATMENT   OF    OBSTRUCTION   DUE   TO 
MECKEL'S  DIVERTICULUM. 

Fitz,  who  devoted  to  this  subject  a  most 
thorough  and  exhaustive  study  in  1884, 
arrives  at  the  following  conclusions: 

"1.  Bands  and  cords  as  a  cause  of  acute 
intestinal  obstruction  are  second  in  impor- 
tance to  intussusception  alone. 

"2.  Their  seat,  structure,  and  relation 
are  such  as  frequently  to  admit  their  origin 
from  obliterated  or  patent  omphalomesen- 
teric vessels,  either  alone  or  in  connection 
with  Meckel's  diverticulum,  and  oppose 
their  origin  from  peritonitis. 

"3.  Recorded  cases  of  intestinal  strangulation  from  Meckel's  diverticulum,  in 
most  instances,  at  least,  belong  in  the  above  series. 

"4.  In  the  region  where  these  congenital  causes  are  most  frequently  met  with,  an 
occasional*  cause  of  intestinal  strangulation,  viz.,  the  vermiform  appendage,  is  also 
found. 

"  5.  It  would  seem,  therefore,  that,  in  the  operation  of  abdominal  section  for  the 
relief  of  acute  intestinal  obstruction  not  due  to  intussusception,  and  in  the  absence 
of  local  symptoms  calling  for  the  preferable  exploration  of  other  parts  of  the 
abdominal  cavity,  the  lower  right  quadrant  should  be  selected  as  the  seat  of  the 
incision.  The  vicinity  of  the  navel  and  the  lower  three  feet  of  the  ileum  should  then 
receive  the  earliest  attention.  If  a  band  is  discovered,  it  is  most  likely  to  be  a  per- 
sistent vitelline  duct,  Meckel's  diverticulum,  or  an  omphalomesenteric  vessel,  either 
patent  or  obliterated,  or  both  these  structures  in  continuity.  The  section  of  the 
band  may  thus  necessitate  opening  the  intestinal  canal  or  a  blood-vessel  of  large  size. 
Each  of  these  alternatives  is  to  be  guarded  against,  and  the  removal  of  the  entire 
band  is  to  be  sought  for,  lest  subsequent  adherence  prove  a  fresh  source  of  strangu- 
lation." 

"The  chief  practical  conclusion  thus  reached  in  this  article  is  essentially  the  same 


Fig.  103. — Inversion  of  Meckel's  Diverticulum 
into  the  Lumen  of  the  Bowel.  (Redrawn 
after  Kiittner.) 

The  patient  was  a  woman  aged  forty-nine.  In 
this  case  Meckel's  diverticulum  was  virtually  turned 
inside  out,  and  is  seen  lying  in  the  bowel.  The  con- 
dition produced  obstruction  and  death. 


*  If  Reginald  Fitz  were  living  today  and  rewriting  this  paragraph  he  would,  remembering  his 
epoch  -making  studies  on  appendicitis,  replace  "occasional"  by  the  word  "frequent." 


172  THE    UMBILICUS    AND    ITS    DISEASES. 

as  that  of  Nelaton.*  This  surgeon  advised  that  the  incision  through  the  abdominal 
wall  for  the  relief  of  intestinal  obstruction  should  be  made  a  little  above  Poupart's 
ligament,  preferably  in  the  right  side.  The  knuckle  of  intestine  first  presenting 
was  to  be  united  to  the  edges  of  the  wound  and  incised,  an  intestinal  fistula  being 
thus  established.  His  recommendation  was  based  upon  the  applicability  of  this 
operation — enterotomy — to  all  cases  of  intestinal  obstruction,  since  it  is  usually 
impossible  to  make  a  differential  diagnosis  of  the  cause  of  ileus.  The  place  was 
selected  because  a  loop  of  small  intestine  above  the  seat  of  obstruction  is  likely  to 
be  found  in  this  part  of  the  abdomen,  and  it  is  also  likely  to  be  so  far  from  the 
stomach  that  a  sufficiency  of  intestine  for  digestive  purposes  will  be  left  intact. 

'  •  The  due  appreciation  of  the  relative  f requency  of  congenital  causes  of  intestinal 
obstruction  acting  in  the  region  recommended  by  Nelaton  as  the  place  of  operation 
adds  force  to  his  arguments.  The  operation  of  enterotomy  in  the  best  favored 
position  is  still  available,  provided  the  above  causes  of  obstruction  are  not  found." 

These  suggestions,  made  by  Nelaton  in  1857,  and  by  Fitz  in  1884,  are  in  thorough 
accord  with  the  surgical  views  of  to-day.  Thirty  years  have  elasped  since  Fitz 
wrote  his  article.  To-day  the  cases  are,  fortunately,  often  recognized  early. 
The  surgeon  will  make  a  right  rectus  incision,  which  can  be  extended  upward  or 
downward  and  the  obstruction  relieved  or  the  cause  removed,  as  the  case  may  be. 
In  addition  to  this,  due  consideration  must  be  given  to  the  question  whether  the 
partly  paralyzed  bowel  can  expel  its  contents  even  after  the  obstruction  has  been 
removed.  If  there  is  any  doubt  on  this  point,  it  is  the  duty  of  the  surgeon  to  bring 
up  a  loop  of  bowel  above  the  point  where  obstruction  has  existed,  attach  it  to  the 
abdominal  wall,  and  open  it  a  few  hours  later. 

In  the  late  cases,  when  the  patient  is  too  weak  for  any  prolonged  operation  look- 
ing to  the  relief  of  the  obstruction,  a  loop  of  the  distended  bowel  should  be  brought 
up  into  the  incision  and  an  enterostomy  made  with  the  hope  that  in  a  few  days  the 
patient  will  be  strong  enough  to  withstand  the  more  radical  procedure. 

*  Xelaton:  I/Union  medicale,  1857,  xi,  Xos.  89,  91,  93. 


LITERATURE  CONSULTED  ON  MECKEL'S  DIVERTICULUM. 
Beck,  B.:  Ueber  das  angeborne  Divertikel  des  Rrummdarms.     Illustr.  Med.  Zeitung,  Munchen, 

1852,  ii,  294. 
Bize:   Etude  anatomo-clinique  des  pancreas  accessoires  situes  a  l'extremite  d'un  diverticule  in- 
testinal.    Revue  d'orthopedie,  1904,  xv,  149. 
Blanc,  H. :  Contribution  a  la  pathologie  du  diverticule  de  Meckel.     These  de  Paris,  1899,  No.  393. 
Cazin,  Henry:    Etude  anatomique  et  pathologique  sur  les  diverticules  de  l'intestin.     These  de 

Paris,  1862,  No.  138. 
Denuce:   Fistules  pseudo-pyloriques  congenitales  de  l'ombilic.     Revue  d'orthopedie,  190S,  xix,  1. 
Deve,  F.:  Des  teratomes  "enteroides."     A  l'occasion  d'un  cas  de  "tumeur  entero'ide  pancrcati- 

forme."     La  Normandie  med.,  1906,  xxi,  169. 
Elliot,  J.  W.:  Strangulation  of  Meckel'-S  Diverticulum  Caused  by  Volvulus  of  the  Ileum.     Trans. 

Amer.  Surg.  Assoc,  1894,  xii,  217. 
Fitz,  R.  H.:   Persistenl  Omphalomesenteric  Remains:  their  Importance  in  the  Causation  of  In- 

tesl  inal  Duplication,  Cyst-formation,  and  Obstruction.     Amer.  Jour.  Med.  Sci.,  1884,  lxxxviii, 

30. 
Huggins,  R.  R.:  Personal  communication. 
Jordan,  Max:    Ueber  Ileus  verursacht  durch  den  persistirenden  Ductus  ornphalo-mesaraicus. 

B'-rlin.  klin.  Wochenschr.,  1896,  xxxiii.  25. 
Kelly  and  Hurdon:  The  Vermiform  Appendix  and  its  Diseases.     W.  B.  Saunders  Co.,  1905. 


Meckel's  diverticulum.  173 

Kern,  T. :    Leber  die  Divertikel  des  Darmkanals.     Inaug.  Diss.,  Tubingen,  1874. 
King,  T.  W.:    A  Feculent  Discharge  at  the  Umbilicus  from  Communication  with  the  Diver- 
ticulum Ilei.     Guy's  Hospital  Reports,  1843,  i,  2.  series,  467. 
Ki'ittner,  H.:    Ileus  durch  Intussusception  eines  Meckel'schen  Divertikels.     Beitrage  zur  khn. 

Chir.,  189S,  xxi,  289. 
Lowenstein:  Der  Darmprolaps  bei  Persistenz  des  Ductus  omphalo-mesentericus,  mit  Mittheilung 

eines  operativ  geheilten  Falles.     Langenbeck's  Arch.  f.  khn.  Chir.,  1894-95,  xlix,  541. 
Meckel,  Johann  Friedrich:  Handbuch  der  pathologischen  Anatomie,  1812,  i,  553. 
Richardson,  W.  G.:    A  Case  of  Abnormally  Large  Meckel's  Diverticulum  found  Postmortem. 

Quart,  Med.  Jour.,  1894-95,  iii,  267. 
Schroeder,  G. :  Ueber  die  Divert ikel-Bildungen  am  Darm-Kanale.     Inaug.  Diss.,  Augsburg,  1854. 
Sheen,  W.:  Some  Surgical  Aspects  of  Meckel's  Diverticulum.     Bristol  Medico-Chir.  Jour.,  1901, 

jrix,  310. 
Struthers,  John:  Anatomical  and  Physiological  Observations,  Edinburgh,  Part  I,  1854,  137. 
Tillmanns,  H. :  Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring  (Ectopia 

Ventriculi)  und  iiber  sonstige  Geschwulste  und  Fisteln  des  Nabels.     Deutsche  Zeitschr.  f. 

Chir.,  1882-83,  xviii,  161. 
Treves,  Frederick:  Allbutt's  System  of  Medicine,  1897,  iii,  802. 
Ward,  X.:    Fatal  Intestinal  Obstruction  in  Consequence  of  a  Twist  in  the  Mesentery  and  the 

Falling  of  Some  Folds  of  Intestine  over  a  true  Diverticulum.     Trans.  Path.  Soc.  London, 

1856,  vii,  205. 
Wilks,  Samuel:    Strangulation  of  Intestine  by  Diverticulum  Ilei.     Trans.  Path.  Soc.  London, 

1865,  xvi,  126. 


CHAPTER  IX. 
INTESTINAL  CYSTS. 

Classification. 

Intestinal  cysts  developing  from  the  omphalomesenteric  duct  or  Meckel's  diverticulum. 

1.  Intestinal  cysts  lying  relatively  free  in  the  abdomen. 

2.  Intestinal  cysts  lying  between  the  layers  of  the  mesentery. 

3.  A  cyst  of  the  central  portion  of  the  omphalomesenteric  duct. 
Symptoms  of  intestinal  cysts. 

Treatment. 

Interesting  cases  of  intestinal  cysts  were  recorded  by  Cazin  in  1862,  and  by 
Hennig  in  1880,  but  it  is  to  the  splendid  article  of  Roth,  published  in  1881,  that  we 
are  indebted  for  the  first  clear  and  exhaustive  presentation  of  the  subject. 

Fitz,  in  his  monograph  in  1884,  dealt  with  intestinal  cysts  at  length. 

Runkel  reported  an  interesting  series  of  cases  in  1897,  and  his  admirable  article 
should  be  read  by  all  who  desire  to  acquire  a  full  knowledge  of  the  subject.  In 
addition  to  his  own  cases  he  reported  the  observations  of  Roth,  Tscherning,  Ditt- 
rich,  Nasse,  Buchwald,  Kulenkampff,  Huter,  Rimbach,  and  Lohlein. 

In  1906  Colmers  published  an  article  upon  intestinal  cysts  and  their  treatment. 
He  says  that  Raesfeld  was  the  first  to  describe  an  enterocystoma,  and  that  he  drew 
attention  to  the  fact  that  it  developed  from  what  we  now  call  Meckel's  diverticulum. 

Roth  says  that  these  sacs  are  filled  with  fluid,  and  that  the  structure  of  their 
walls  resembles  more  or  less  that  of  the  intestinal  canal.  He  divides  intestinal 
cysts  into  two  groups: 

Group  I  .  ■ — ■  Those  in  which  the  originally  normally  formed  intestinal 
tract  is  divided  into  several  isolated  cystic  sacs.  The  division  of  the  intestine  occurs 
usually  as  a  result  of  a  peritonitis,  and  according  to  Rokitansky,  occasionally  as  a 
result  of  a  twisting  of  the  mesentery.  In  such  cases  the  nipping-off  of  the  bowel  into 
isolated  segments  naturally  severs  its  continuity  and  soon  causes  the  death  of  the 
child. 

Group  II.  —  To  the  second  group  belong  the  intestinal  cysts  which  origi- 
nate from  an  abnormal  development  of  the  intestinal  tract.  The  cysts  are  present, 
but  we  also  have  a  permeable  intestinal  canal;  consequently  from  this  standpoint 
the  life  of  the  child  is  not  in  danger. 

Roth  subdivides  Group  II  into  three  varieties: 

A.  Superfluous  and  cystically  dilated  portions  of  the  intestine  belonging  to 
rudimentary  twin  pregnancies,  as  in  Case  E  of  Scharer-Klebs,  in  Klebs'  Handbuch 
der  spec.  path.  Anat,,  i,  1013. 

B.  Intestinal  cysts  occurring  in  combination  with  abnormal  deposits,  and 
occasionally  with  growing  organs  and  portions  thereof.  In  this  group  he  included  a 
case  of  Sanger  and  Klopp.  In  this  connection  it  may  be  of  interest  to  refer  to  a  case 
observed  by  Simmons  and  reported  by  Cazin  in  1862.  The  patient  was  a  well- 
formed  female  child,  two  years  old.  At  autopsy  a  tumor  was  found  situated  at  the 
base  of  the  vertebral  column.     It  consisted  of  fat,  bones,  etc.,  and  also  contained  a 

174 


INTESTINAL    CYSTS. 


175 


large  quantity  of  intestine,  part  of  which  belonged  to  the  ileum  and  part  to  the  colon, 
the  appendix  being  attached  to  the  latter. 

[Several  years  ago,  while  opening  a  dermoid  cyst  the  size  of  a  child's  head  at  the 
Johns  Hopkins  Hospital,  I  found  that  it  contained  a  relatively  large  cavity  partly 
filled  with  fluid.  This  cavity  also  contained  a  perfectly  formed  loop  of  small  bowel 
(Fig.  104).     The  tumor  was  opened  immediately  after  its  removal  and  while  still 


. 


Fig.  104. — -A  Well-developed  Loop  of  Small  Bowel  ix  a  Dermoid  Cyst  of  the  Ovary. 
Gyn.  No.  14118.  Path.  No.  11728.  The  patient  was  a  white  woman,  twenty-eight  years  old,  who  had  a  cyst  of 
the  left  ovary  about  16  cm.  in  diameter.  When  the  cyst  was  opened,  a  large  cavity,  partly  filled  with  sebaceous-like 
material  and  hair,  was  found,  and  at  one  side  was  a  well-developed  loop  of  small  bowel.  This  had  a  well-defined  mesen- 
tery, and  on  being  handled  the  bowel  contracted,  showing  a  definite  peristalsis.  August  Horn  at  once  made  a  sketch 
of  this  rare  condition.  The  specimen  has  disappeared,  and  Mr.  Brodel  has  made  the  drawing  from  Horn's  original 
sketch. 


warm.  It  was  easy  to  follow  the  wave  of  contraction  in  the  bowel,  just  as  in  the 
normal  intestine.] 

C.  A  simple  intestinal  cyst  developing  from  the  adherent  normal  lateral 
appendages  of  the  intestine,  most  frequently  from  Meckel's  diverticulum. 

A  full  discussion  of  the  entire  subject  of  intestinal  cysts  does  not  come  within 
the  province  of  this  book.  We  must,  however,  carefully  consider  Class  C,  in  Roth's 
Group  II,  to  which  belong  intestinal  cysts  probably  arising  from  remnants  of  the 
omphalomesenteric  duct  or  from  Meckel's  diverticulum. 


176 


THE    UMBILICUS    AND    ITS    DISEASES. 


Fig.  105. — An  Intestinal  Cyst.  (Sche- 
matic.) 
Most  of  the  intestinal  cysts  found  have 
been  due  to  partial  or  complete  torsion  of 
Meckel's  diverticulum,  which  had  taken 
place  so  gradually  that  no  gangrene  oc- 
curred. In  rare  instances  both  the  outer  and 
inner  ends  of  the  omphalomesenteric  duct 
become  obliterated,  while  the  central  por- 
tion remains  patent.  The  accumulation  of 
the  secretion  from  the  mucosa  in  time  pro- 
duces an  intestinal  cyst.  The  above  is  a 
schematic  representation  of  a  small  intes- 
tinal cyst  of  this  nature. 


INTESTINAL  CYSTS  DEVELOPING  FROM  THE  OMPHALOMESENTERIC  DUCT  OR 

MECKEL'S  DIVERTICULUM. 

From  a  survey  of  the  recorded  cases  it  is  perfectly  clear  that  these  cysts  may  be 
divided  into  two  groups: 

1.  Intestinal  cysts  lying  relatively  free  in  the  abdomen. 

2.  Intestinal  cysts  lying  between  the  layers 
of  the  mesentery. 


INTESTINAL  CYSTS  LYING  RELATIVELY  FREE  IN 
THE  ABDOMEN. 

Tiedemann,  Carwardine,  Hendee,  Rimbach, 
Roth,  and  Fitz  have  reported  cases  of  this  char- 
acter. In  Tiedemann's  case,  published  in  1813, 
a  pear-shaped  cyst,  14.5  x  7  Linien*  was  attached 
to  the  convex  surface  of  the  bowel  by  a  pedicle 
3.5  Linien  long.  The  cyst  communicated  with 
the  bowel  through  the  pedicle. 

In  Carwardine's  case  the  tumor  occupied  the 
right  upper  abdomen  and  was  twisted.  Its  pedi- 
cle was  attached  to  the  small  bowel.  The  cyst 
was  densely  adherent. 

In  Hendee 's  case  the  tumor  consisted  of  two 
portions.     One  portion  lay  in  an  inguinal  hernia. 
The  tumor  was  attached  to  the  convex  surface  of 
the  small  bowel. 

In  Rimbach's  case  the  tumor  was  the  size  of 
a  man's  head,  wrapped  up  in  omentum,  and  at- 
tached to  the  small  bowel  by  a  solid  co*rd. 

In  Roth's  case  the  tumor  measured  6.2  x  5.3  x 
3.6  cm. ;  it  was  cystic  and  enveloped  in  omentum. 
It  sprang  from  the  mesenteric  attachment  of  the 
bowel  by  a  twisted  pedicle.  The  pedicle  had  a 
lumen  which  was  patent. 

It  is  evident  that  in  these  cases  the  cystic 
tumor  had  originated  from  a  Meckel's  divertic- 
ulum (Fig.  105). 

The  tumor  tends  to  become  adherent  to  the 
omentum  and  to  the  neighboring  structures 
(Fig.  106).  The  inner  surface  of  the  cyst  is  lined 
with  intestinal  mucosa,  which  may  be  somewhat 
inflamed. 

The  character  of  the  cyst  contents  will  de- 
pend on  whether  or  not  there  is  a  connection 
with  the  intestinal  cavity.  In  those  cases  in 
which  the  cyst  has  been  cut  off  before  meconium 

has  had  a  chance  to  get  into  it,  the  contents  will  be  glairy  mucus  mixed  with  ex 
foliated  epithelium  and  sometimes  with  a  little  pus  and  blood. 

*  A  Linie  varied  from  one-twelfth  to  one-tenth  of  an  inch. 


Adh 


Fig.  106. — An  Intestinal  Ctst  Attached 
to  the  Umbilicus  by  a  Pedicle  but 
not  Connected  with  the  Bowel. 
(Schematic.) 

On  comparing  the  cyst  with  the  bowel, 
it  is  found  to  be  several  centimeters  in  diam- 
eter. It  is  attached  to  the  umbilicus  by  a 
well-developed  and  twisted  pedicle.  The 
omentum  is  plastered  over  its  surface,  and 
below  it  is  adherent  to  the  appendix  and 
cecum.  The  small  bowel  has  a  tag  project- 
ing from  it,  possibly  at  the  point  where  the 
omphalomesenteric  duct  formerly  existed. 
The  picture  is  a  schematic  representation 
of  a  condition  very  rarely  noted. 


INTESTINAL    CYSTS. 


177 


Adh. 


CoLo  i 


An  Intestinal  Cyst  Developing  from  a  Meckel's  Di- 
verticulum. —  Tiedemann,*  quoted  by  Roth,f  in  examining  a  male  fetus 
at  term  with  a  double-sided  harelip  and  an  accessory  little  finger  on  each  hand, 
observed  an  umbilical  hernia  the  size  of  a  large  walnut.  In  this  lay  a  portion  of 
intestine.  It  showed  a  pear-shaped,  bladder-like  formation,  14.5  LinienX  long  and 
7  Linien  in  its  transverse  diameter.  It  had  a  pedicle  3.5  Linien  long,  and  lay  attached 
to  the  convex  surface  of  the  intestine  by  a  narrow  canal  which  admitted  a  probe. 
The  bladder-like  projection  contained  whitish-yellow  fluid,  and  had  originated 
through  a  canal  communicating  with  the  cavity  of  the  intestine. 

Volvulus  of  Meckel's  Diverticulum.  §  —  The  patient  was 
a  child,  two  days  old,  who 
had  intestinal  obstruction  and 
greenish  vomiting.  There  was 
no  fecal  matter  passing  by 
the  bowel  and  no  discharge 
from  the  umbilicus.  The  ab- 
domen was  much  distended. 
Rectal  examination  was  nega- 
tive. The  child  was  watched 
for  six  hours,  but  nothing- 
passed  by  the  bowel. 

When  the  abdomen  was 
opened,  the  small  intestine 
was  found  to  be  very  much 
distended  and  covered  with 
lymph.  The  colon  was  not 
larger  than  a  crow's  quill, 
whitish-yellow  in  color,  and 
non-sacculated.  A  mass  could 
be  felt  to  the  right  of  the  um- 
bilicus. Here  the  gut  was 
much  distended,  and  there 
were  so  many  adhesions  that 
the  bowel  could  not  be  brought 
out.  The  source  of  the  ob- 
struction could  not  be  determined,  but  at  autopsy  was  found  to  be  due  to  an 
anomaly  of  Meckel's  diverticulum. 

An  artificial  anus  was  made,  and  several  ounces  of  meconium  escaped.  The 
cecum  and  ascending  colon  were  found  to  be  hard  and  small.  The  child  died  twenty- 
four  hours  later.  The  cyst  was  made  up  of  a  greatly  distended  Meckel's  diverticu- 
lum with  three  twists  (Fig.  107).  Only  a  fine,  impervious  cord  connected  it  with 
the  bowel.  Carwardine  noted  the  following  as  the  points  of  interest  in  this  case:  (1) 
An  acute  commencement  of  peritonitis  before  birth;  (2)  the  occurrence  of  a  volvulus 
of  Meckel's  diverticulum  in  utero  during  late  fetal  life,  so  that  a  meconium-contain- 

*  Tiedemann:  Kopflose  Missgeburten,  1813,  S.  66,  Taf.  i. 
t  Roth:  Virchows  Arch.,  1881,  Ixxxvi,  371. 
t  A  Linie  varied  from  one-twelfth  to  one-tenth  of  an  inch. 
§  Carwardine,  T.:   Brit.  Med.  Jour.,  1897,  ii,  1637. 
13 


Cateroslom 
Op 


Fig.  107. — Volvulus  of  Meckel's  Diverticulum.  (Redrawn  after 
Carwardine.) 
The  child  was  two  days  old  and  had  passed  nothing  by  the  bowel. 
There  was  no  discharge  from  the  umbilicus.  The  abdomen  was  mark- 
edly distended.  At  operation  a  large  sac  was  detected  and  opened, 
but  the  child  died  twenty-four  hours  later.  The  cyst  was  a  greatly 
distended  Meckel's  diverticulum.  This  had  twisted  three  times,  and 
an  impervious  cord  connected  it  with  the  bowel.  The  lower  end  of 
the  small  bowel  was  empty  and  tortuous.  The  colon  was  small  and 
sacculated.     No  meconium  had  ever  reached  the  rectum. 


178 


THE    UMBILICUS   AND    ITS    DISEASES. 


£$>. 


y^ 


%h 


ing  cyst  was  segmented  off  from  the  ileum,  and  consequently  the  obstruction  was  not 
relieved  by  an  opening  into  the  distended  diverticulum;  (3)  the  lower  12  inches  of 
small  bowel  were  empty  and  tortuous.  The  colon  was  small  and  non-sacculated.  No 
meconium  had  ever  passed  into  them;  yet  the  cecum  and  appendix  were  well  formed. 
A  Solid  Tumor*  Probably  Developing  from  Rem- 
nants   of    the    Omphalomesenteric    Duct.f  —  In   an  inguinal 

hernia  there  was  a  small 
cylindric  tumor.  This  com- 
municated with  a  second 
mass,  which  lay  in  a  chronic- 
ally inflamed  omentum  and 
was  connected  by  a  cord  the 
size  of  a  penholder.  The  me- 
dian portion  of  the  last-named 
tumor  was  attached  to  the 
small  intestine  on  its  convex 
side,  32  cm.  above  the  ileo- 
cecal valve.  This  could  be 
traced  to  the  submucosa  of 
the  bowel.  Both  tumors  and 
the  cord  were  completely 
solid,  and  consisted  of  con- 
nective tissue  with  numerous 
deposits  of  chalk.  Colmers 
said  that  Hendee's  case  af- 
fords a  good  example  of  the 
difficulty  of  making  an  ana- 
tomic diagnosis  of  the  remains 
of  the  omphalomesenteric 
duct. 

An  Intestinal 
Cyst  Due  to  Dila- 
tation of  Meckel's 
Diverticulum.  —  In 
Rimbach'sJ  case  there  was 
a  cyst  the  size  of  a  man's 
head.  This  was  wrapped 
up  in  omentum  and  at- 
tached to  the  small  bowel  by 
a  short,  completely  solid  pedicle.  The  cyst  was  not  lined  with  mucosa,  but  in  its 
walls  were  two  definite  layers  of  muscle. 

An  Intestinal  Cyst  Developing  from  a  Diverticulum 
of  the  Ileum  and  Continuing  with  the  Bowel;  Beginning 
Peritonitis     Due    to     Torsion    of     the     Pedicle. §  —  A     boy, 

*  This  tumor,  although  solid,  was  at  first  probably  cystic,  and  is  accordingly  included  here. 
t  Hendee,  cited  by  Colmers:  Arch.  f.  klin.  Chir.,  1906,  lxxix,  132. 
%  Rimbach,  quoted  by  Colmers:   Loc.  cit. 

§  Roth,  M.:    Qeber  Missbildungen  im  Bereich  des  Ductus  omphalomesentericus.     Virchows 
Arch.,  1881,  lxxxvi,  371. 


Fig.  108. — An  Intestinal  Cyst  Developing  from  Meckel's  Diver- 
ticulum.    (After  Roth.) 
The  cyst  in  front  and  above  has  omentum  adherent  to  it.     From 
the  ileum  a  sound  has  been  carried  into  the  hollow  pedicle;   the  latter 
is  crossed  by  a  small  mesentery. 


INTESTINAL    CYSTS.  179 

sixteen  months  old,  up  to  a  month  and  a  half  before  admission,  had  always 
been  healthy.  His  stools  became  irregular,  constipation  and  diarrhea  alternating. 
About  three  weeks  before  admission  the  child  had  to  remain  in  bed  for  two  weeks, 
and  for  three  days  had  marked  vomiting.  He  died  with  definite  signs  of  intestinal 
obstruction.  At  autopsy  the  abdomen  was  found  distended  above  the  umbilicus, 
where  the  intestinal  loops  were  prominent.  Below  the  umbilicus,  in  front  of  the 
mesentery,  was  a  transverse,  oval,  reddish,  moderately  distended  tumor  (Fig.  108). 

This  tumor  was  6.2  cm.  in  its  transverse  diameter,  5.3  cm.  in  its  vertical,  and  3.6 
cm.  in  its  anteroposterior  diameter.  It  was  for  the  most  part  smooth,  but  above 
and  to  the  left  it  was  firmly  adherent.  Above  the  anterior  surface  and  to  the  right 
were  delicate  adhesions  to  the  greater  omentum.  In  the  omentum  large  vessels 
were  seen.  On  the  under  and  right  margin  of  the  tumor  was  a  pedicle  11  mm.  long. 
This  passed  to  the  concave  surface  of  the  ileum,  close  to  the  insertion  of  the  mesen- 
tery. The  cyst  was  situated  66  cm.  above  the  ileocecal  valve.  The  pedicle  con- 
sisted of  two  portions,  one  of  which  was  conic  in  shape  and  measured  11  mm.  in 
breadth  at  the  ileum,  whereas  at  the  tumor  it  was  only  4  mm.  broad.  Along  the 
base  the  intestine  had  become  twisted  from  right  to  left.  The  second  portion  of  the 
pedicle,  which  was  connected  with  the  first,  passed  upward  and  to  the  left  and 
extended  to  the  base  of  the  tumor.  The  pedicle  ended  in  the  mesentery,  and  was 
covered  with  peritoneum.  It  consisted  of  fatty  tissue  and  of  several  vessels  which 
passed  to  the  wall  of  the  tumor;  in  other  words,  this  was  the  mesentery  of  the 
tumor.  When  the  tumor,  which  was  otherwise  free,  was  turned  from  the  left  for- 
ward and  to  the  right  for  90  degrees,  the  torsion  of  the  conic  portion  of  the  intestine 
at  its  crossing  with  the  mesentery  was  released.  The  lower  portion  of  the  abdominal 
cavity  contained  a  few  drops  of  turbid  yellow  fluid.  When  the  cyst  was  opened, 
air  and  32  c.c.  of  thick,  brownish-red  fluid  mixed  with  mucus  and  reddish  flocculi 
escaped.  The  fluid  consisted  almost  entirely  of  pus-cells  intermingled  with  red 
blood-corpuscles  and  cylindric  cells. 

The  reddish  threads  proved  to  be  hemorrhagic  infiltration.  The  wall  of  the 
cyst  was  2  mm.  thick,  and  at  every  point  was  as  well  developed  as  that  of  the  ileum. 
The  inner  surface  was  partly  ulcerated,  but  for  the  most  part  had  a  lining  of  a  soft, 
velvety,  dark-red  membrane.  The  latter  showed,  on  microscopic  examination,  a 
lining  of  cylindric  cells  and  Lieberkuhn's  glands.  Beneath  the  mucosa  came  the  sub_ 
mucosa,  then  the  ring  muscle,  and  then  the  outer  longitudinal  muscle.  In  the  sub- 
serous connective  tissue  were  large  vessels  and  an  abundance  of  fat-cells,  and  then, 
covering  the  cyst,  was  peritoneum.  In  the  lower  part  of  the  cyst,  in  the  swollen, 
dark-red  mucosa,  was  a  minute  opening  not  larger  than  a  linseed,  through  which  a 
sound  could  be  passed  into  the  ileum.  The  conic-shaped  portion  of  the  pedicle 
was  not  larger  than  a  bean.  This  lay  parallel  with  the  long  axis  of  the  intestine 
near  the  mesenteric  border,  but  on  the  concave  side  of  the  intestine. 

From  the  above  it  is  seen  that  the  abdominal  cyst  corresponded  to  the  end  of  the 
diverticulum,  which  still  communicated  with  the  intestine  and  which  had  a  mesen- 
tery. This  diverticulum  showed  a  distinct  intestinal  structure.  It  was  covered 
over  with  an  inflammatory  deposit  and  adherent  omentum.  The  peritonitis  was, 
without  doubt,  due  to  torsion  of  the  pedicle. 

A  Cyst  of  Meckel's  Diverticulum.  — ■  Fitz,*  in  the  Warren 
Museum,  found  the  following  record  in  the  manuscript  catalogue  (under  No.  4903) : 
*Fitz,  R.  H.:  Amer.  Jour.  Med.  Sci.,  1884,  lxxxviii,  30. 


180  THE    UMBILICUS   AND    ITS    DISEASES. 

Diverticulum  from  the  Small  Intestine.  —  The  specimen 
was  obtained  at  autopsy  from  a  patient  dead  of  chronic  pleurisy.  There  were  no 
symptoms  during  life  to  call  attention  to  its  existence.  It  was  given  off  from  the 
small  intestine  about  1  meter  above  the  ileocecal  valve.  It  was  3  cm.  in  length 
and  about  1  cm.  in  diameter.  There  was  no  apparent  communication  with  the 
lumen  of  the  intestine.  This  specimen  was  a  cyst  of  the  diverticulum,  the  origin 
of  which  was  near  the  mesenteric  attachment.  Its  walls  consisted  of  a  peritoneal 
envelope  with  loose  subperitoneal  connective  tissue,  both  continued  directly  from 
the  intestine.  There  was  a  dense  middle  coat,  resembling  in  appearance  the  mus- 
cular layer  of  the  intestine,  although  elongated  nuclei  were  not  to  be  made  out; 
finally,  an  inner  membranous  lining,  upon  the  free  surface  of  which  occasional  club- 
shaped  stunted  villi  were  found  to  project.  Pouch-like  depressions  with  circular 
openings  upon  the  free  surface  were  found  scattered  throughout  this  membrane. 
Epithelium  was  not  present.  The  middle  and  internal  coats  were  in  the  closest 
proximity  to  the  corresponding  layers  of  the  ileum. 

Fitz  speaks  of  cysts  noted  in  the  region  of  the  duodenum,  and  cites  a  case  of  a 
cyst  of  the  esophagus  observed  by  Wyss.  He  mentions  cases  reported  by  Roth 
and  Hennig  in  which  there  were  cysts  in  the  vicinity  of  the  esophagus. 


INTESTINAL  CYSTS  LYING  BETWEEN  THE  LAYERS  OF  THE  MESENTERY. 

Cases  of  this  character  have  been  recorded  by  Buchwald,  Hennig,  Kulenkampff , 
and  others.  The  cysts  are  situated  in  the  mesentery  of  the  bowel,  usually  a  short 
distance  from  the  ileocecal  valve .  They  may  be  round  or  pipe-shaped.  They  show 
a  peculiar  tendency  to  form  sickle-like  contractions  on  their  inner  surface.  The 
cyst  is,  accordingly,  partially  divided  into  separate  chambers.  These  partial  divi- 
sions may  completely  block  off  a  portion  of  the  cyst,  giving  rise  to  an  isolated  and 
walled-off  secondary  cyst.  The  cysts  may  or  may  not  communicate  with  the 
lumen  of  the  bowel.  They  are  lined  with  intestinal  mucosa.  Where  they  are 
completely  shut  off  from  the  bowel,  they  may  be  filled  with  clear  fluid,  as  was 
noted  in  Hennig's  case,  in  which  the  tumor  reached  large  proportions,  measuring 
22  x  14  x  10  cm. 

A  Large  Intramesenteric  Enterocystoma.*  — ■  The  pa- 
tient had  a  large  intramesenteric  double  cyst.  This  at  one  point  showed  an  epi- 
thelial lining.     It  communicated  with  the  bowel. 

Intestinal  Cyst  and  an  Esophageal  Cyst  in  a  New- 
born I  n  f  a  n  t  .  f  — In  this  case  the  labor  was  a  very  difficult  one,  and  the 
child  died  before  delivery.  A  hook  was  introduced  into  the  chest  and  then  a  perfora- 
tion was  found  advisable.  Pressure  on  the  abdomen  caused  a  discharge  of  about  3000 
c.c.  of  clear  fluid  from  the  child.  The  mother  made  a  good  recovery.  The  length 
of  the  child's  body  was  45  cm.  In  the  abdomen  was  a  sac  which  had  not  been 
injured,  and  reminded  one  of  a  partially  filled  stomach  of  a  grown  person.  Passing 
to  it  were  numerous  large  blood-vessels,  which  behind  and  in  front  of  it  went  to 
the  ileum. 

The  ileum  lay  peripherally  to  the  sac,  near  the  point  where  it  passed  over  into 

*  Buchwald:   (Colmers,  Loc.  cit.). 

t  Hennig,  C:    Cystis  intestinalis,  Cystis  citra  cesophagum  bei  einem  Neugeborenen.     Cen- 
tralbl.  f.  Gyn.,  1880,  iv,  39S. 


INTESTINAL    CYSTS.  181 

the  cecum.  There  was  no  communication  between  the  ileum  and  the  sac.  The 
sac  was  22  cm.  long,  14  cm.  broad,  and  10  cm.  thick.  It  contained  about  100  c.c. 
of  almost  clear,  slightly  reddish,  somewhat  sticky  fluid,  which  was  suggestive  of 
intestinal  fluid.  The  large  bowel  was  empty  and  much  contracted.  (We  have 
purposely  omitted  a  description  of  the  esophageal  cyst.) 

Microscopic  examination  showed  that  the  intestinal  cyst  was  lined  with  cylin- 
dric  epithelium;  in  its  walls  intestinal  glands  were  demonstrable.  The  sac  was  a 
large  intestinal  cyst  which  lay  in  the  mesentery.  This  specimen  was  examined  by 
Weigert. 

An  Intestinal  Cyst;  Death  From  Intestinal  Obstruc- 
tion.* —  The  patient,  a  poorly  developed  boy  three  years  old,  had  died  with 
signs  of  intestinal  obstruction.  At  autopsy  a  cyst  was  found  in  the  mesentery  of 
the  small  bowel,  40  cm.  from  the  ileocecal  valve.  It  was  the  size  of  a  man's  fist, 
had  very  thin  walls,  and  was  almost  translucent.  It  had  several  sickle-like  con- 
strictions, partially  dividing  it  into  semi-spheroid  sacs.  There  was  no  communica- 
tion with  the  bowel.  The  cyst  was  filled  with  very  thin,  chocolate-colored  fluid. 
Kulenkampff  refers  to  Roth's  article.  In  this  case  no  microscopic  examination 
was  made. 

In  the  following  case,  recorded  by  Roth,f  there  was  not  only  a  cyst  attached  to 
the  bowel,  but  also  one  in  the  mesentery  and  another  in  the  thorax : 

A  Congenital  Intestinal  Cyst  Separated  From  a 
Diverticulum  Situated  in  the  Mesentery;  In  Addition, 
Intestinal  Cysts  of  the  Abdominal  and  Thoracic  Cav- 
ities; Compression  of  the  Air-passages.- — ■  The  specimen  and 
the  history  came  from  Roth's  colleague,  J.  J.  Bischoff.  Elsie  B.,  aged  nineteen 
years,  was  delivered  easily.  Immediately  after  there  was  an  escape  of  3000  c.c. 
of  amniotic  fluid.  The  child,  a  male,  was  small.  Movement  of  its  extremities 
was  noted,  and  an  attempt  to  breathe  was  detected.  The  abdomen  was  markedly 
distended.  Notwithstanding  artificial  respiration,  the  child  died  in  ten  minutes. 
The  body  was  42  cm.  long.  There  was  marked  edema  of  the  umbilical  cord;  on 
the  left  side  was  a  hydrocele.  When  the  greatly  enlarged  abdomen  was  opened,  a 
large,  thin-walled  cystic  tumor  with  numerous  vessels  covering  it  was  found  be- 
neath the  liver.  This  tumor  covered  the  stomach  and  the  duodenum.  A  few  loops 
of  small  bowel  lay  over  the  tumor;  others  lay  to  the  left,  and  through  the  walls  of 
the  latter  a  small  quantity  of  meconium  could  be  seen. 

A  more  careful  examination  of  the  tumor  showed  that  it  consisted  of  two  parts : 
the  one  on  the  left  and  in  front  was  the  size  of  a  hen's  egg  (Fig.  109,  6);  the 
other  (&')  was  only  a  third  as  large.  The  latter  lay  in  the  cecal  region,  and  the 
cecum  was  pushed  over  to  the  median  fine.  The  stomach  was  in  the  normal  posi- 
tion, and  contained  a  little  tenacious,  yellowish  mucus.  The  spleen,  adrenals,  kid- 
neys, and  bladder  showed  nothing  unusual.  The  thymus  gland  was  the  size  of  a 
hazel-nut.  The  lungs  were  atelectatic.  The  pleurae  showed  ecchymotic  spots.  The 
foramen  ovale  was  the  size  of  a  pea.     Near  the  right  lung,  and  covered  by  it,  was 

*  Kulenkampff,  D.:  Ein  Fall  von  Enterokystom.  Tod  durch  Darraverschlingung.  Cen- 
tralbl.  f.  Chir.,  1883,  x,  679. 

f  Roth,  M.:  Ueber  Missbildungen  im  Bereich  des  Ductus  omphalomesentericus.  Virchows 
Arch.,  1881,  lxxxvi,  371. 


182 


THE    UMBILICUS   AND    ITS    DISEASES. 


a  fluctuating  tumor  which  sprang  from  the  vertebral  column  and  was  covered  by 
the  costal  pleurae.  The  esophagus  passed  obliquely  above  the  left  half  of  the 
tumor,  and  was  easily  dissected  from  it  (Fig.  109,  c). 


Fig.   109. — Intestinal  Cysts  in  the  Abdominal  Cavity.     (After  Roth.) 
The  heart,  lungs,  and  liver  have  been  removed.     The  ascending  colon  has  been  thrown  to  the  left,  and  the  pedicle 
of  the  cysts  (b  and  b')  has  been  freed.     On  the  upper  surface  of  the  cyst  (b)  are  several  lymph-glands.     The  spleen, 
stomach,  duodenum,  and  the  right  kidney  are  visible;    also  remnants  of  the  diaphragm.     To  the  left  of  the  cyst  (c), 
which  lay  in  the  thoracic  cavity,  are  the  esophagus  and  the  doubly  cut  aorta. 


There  was  a  marked  swelling  over  the  left  temporal  vein,  and  numerous  ecchy- 
moses  wore  encountered  in  the  dura.     The  pia  mater  was  edematous,  and  the  vessels 


INTESTINAL    CYSTS. 


183 


>  >  J&&  » 


were  engorged  and  tortuous.  The  ventricles  were  dilated  and  contained  bloody 
fluid. 

In  the  abdominal  cavity,  in  addition  to  the  above-mentioned  tumors  (Fig.  109, 
b  and  b'),  there  was  still  another  which  lay  between  the  layers  of  the  mesentery 
and  close  to  the  lower  portion  of  the  ileum.  This  was  a  sausage-shaped  cyst  (Fig. 
110,  a),  which  lay  close  to  the  concave  wall  of  a  loop  of  the  ileum.  The  mesenteric 
vessels  passed  on  the  top  of,  over,  and  beneath  the  tumor  to  the  intestinal  canal, 
and  from  these  vessels  numerous  small  branches  went  into  the  cyst.  This  mass 
itself  resembled  a  sausage  and  was  somewhat  club-shaped.  Its  upper  end  was 
directed  toward  the  jejunum,  and  it  had  a  knob-like  end,  13  mm.  broad.  Here 
the  tumor  had  a  greater  diameter  than  the  small  intestine.  The  smaller,  lower 
end  terminated  in  an  extremity  having  a  diameter  of  over  5  mm. 

When  the  ileum  was  opened,  it  was  seen  that  the  lower  end  of  the  mesenteric 
tumor  projected  into  the  intes- 
tine and  then  opened  into  it 
through  a  roundish  aperture 
(Fig.  110,  x).  The  opening  fol- 
lowed the  direction  of  a  very 
acute  angle.  In  the  picture  the 
edges  of  the  opening  have  been 
spread  with  a  glass  rod,  and  in 
this  way  the  original  prominence 
has  been  much  exaggerated. 
The  opening  was  situated  at  a 
point  14.5  cm.  above  the  ileo- 
cecal valve.  The  length  of  the 
club-shaped  tumor  was  10  cm. 
A  sound  introduced  into  the  in- 
tramesenteric  diverticulum  en- 
countered several  ring-like  nar- 
rowings  through  which  only  a 
bristle  could  be  passed.  The 
swollen  end  of  the  diverticulum 
(Fig.  110,  a)  did  not  admit  the 

sound.  On  being  opened,  it  was  seen  that  in  this  portion  was  a  cyst  the  size  of  a  bean 
that  had  been  completely  cut  off  from  the  remaining  portion  of  the  diverticulum. 
The  diverticulum  contained  no  yellowish  material,  but  in  the  lower  portion  was 
mucus.  The  small  cyst  contained  thick  masses  which,  on  microscopic  examina- 
tion, showed  numerous  glistening  round-cells  without  nuclei. 

The  walls  of  the  diverticulum  were  similar  to  those  of  the  intestinal  canal,  and 
the  inner  surface  was  lined  with  a  single  row  of  cylindric  goblet-cells  with  Lieber- 
kuhn's  glands  beneath.  The  small  cyst  was  different  in  structure.  The  outer 
coats  were  similar  to  those  of  other  portions  of  the  diverticulum.  The  septum  be- 
tween the  cyst  and  the  diverticulum  did  not  contain  longitudinal  muscle  in  the 
subserous  layers.  The  mucosa  was  very  thin.  The  upper  surface  was  partly  flat. 
Lieberkiihn's  glands  were  entirely  wanting.  The  inner  surface  was  lined  with 
ciliated  epithelium. 

The  abdominal  cyst,  which  consisted  of  two  apparently  separate  sacs  (Fig.  109, 


Fig.  110. — An  Intramesenteric  Ctst.  (After  Roth.) 
The  specimen  shows  the  lower  portion  of  the  ileum,  with  the 
mesentery,  vermiform  appendix,  and  ascending  colon.  The  anterior 
fold  of  the  mesentery  has  been  removed.  The  branching  of  the  su- 
perior mesenteric  vein  and  the  larger  portion  of  the  diverticulum  lie 
on  the  concave  side  of  the  intestine  and  have  been  dissected  free. 
a  is  the  outer  cyst,  which  has  been  but  incompletely  developed 
from  the  diverticulum,  x  indicates  the  ostium,  which  has  been 
made  visible  through  the  splitting  open  of  the  intestine. 


184  THE    UMBILICUS    AND    ITS    DISEASES. 

b  and  6'),  anteriorly,  above,  and  below  was  covered  with  a  glistening  peritoneum, 
and  occupied  a  large  portion  of  the  middle  of  the  right  abdominal  cavity.  Both 
sacs  were  easily  moved  on  one  another  in  various  directions.  Only  in  the  region 
of  the  pancreas  and  on  the  lower  portion  of  the  duodenum  were  they  fixed.  On 
dissection  it  was  found  that  there  was  a  short  pedicle,  1  cm.  long,  between  the  an- 
terior round  and  the  lower  sausage-like  mass.  The  pedicle  was  2  mm.  broad,  and 
had  a  canal  0.5  mm.  in  diameter,  which  joined  the  two  cavities.  There  was  no 
open  connection  between  the  intestinal  canal  and  the  cysts.  The  whole  tumor,  on 
its  posterior  and  left  side,  was  attached  by  a  rather  firm  connective  tissue  to  the 
superior  mesenteric  artery  from  its  point  of  origin  beneath  the  pancreas.  There 
was  no  direct  connection  with  the  vertebral  column. 

The  superior  mesenteric  artery  was  1.6  mm.  thick,  and  formed  in  its  middle 
course  three  ring-shaped  anastomoses.  It  gave  off  from  its  right  side,  9  mm.  below 
the  art.  colica  dextra,  the  art.  ileo-colica,  which  was  1  mm.  in  diameter.  The 
largest  branch  of  this  supplied  the  cyst  (6).  Eleven  millimeters  further  on,  it  gave 
off  a  branch  which  supplied  the  small  cyst  (&')• 

On  the  upper  surface  of  the  cyst  these  vessels  formed  an  extensive  network  which, 
on  the  one  side,  anastomosed  with  the  arteriae  intestinales,  and  on  the  other  side 
with  the  arteria  colica  dextra.  The  veins  had  relations  similar  to  those  of  the 
arteries.    There  were  numerous  nerves  and  also  veins  over  the  surface  of  the  cyst  (6) . 

Lymph-glands  were  also  present  under  the  serosa. 

Thus  the  large  abdominal  cyst  was  retroperitoneal  in  the  right  portion  of  the 
mesentery,  and  had  pushed  the  mesentery  in  a  pouch-like  manner  before  it.  It  was 
supplied  by  two  branches  of  the  superior  mesenteric  artery.  The  portion  (6)  con- 
tained 34  c.c.  of  tenacious,  somewhat  flocculent  fluid.  The  fluid  gave  a  reaction 
for  mucin.  The  inner  surface  of  the  cyst  was  smooth.  The  thickness  of 
the  wall  varied:  near  the  vertebral  column  it  reached  a  maximum  of  1.5  to 
2  mm.  On  microscopic  examination  all  the  layers  of  the  intestinal  wall  could 
be  identified.  The  mucosa,  however,  was  very  thin,  and  only  where  the 
inner  surface  was  rough  were  there  villus-like  elevations.  The  inner  surface  was 
lined  with  cylindric  epithelium,  but  the  mucosa  was  hardly  sufficiently  developed 
to  form  glands.  The  portion  (&')  corresponded  in  the  main  with  (6)  and  only 
differed  in  that  the  walls  were  thinner  and  there  were  more  folds.  The  surface  was 
lined  with  cylindric  cells  and  goblet-cells,  and  here  and  there  in  the  depth  were  real 
gland-like  spaces.  The  sac  contained  7.5  c.c.  of  fluid.  Lining  the  canal  between 
the  two  sacs  were  cylindric  cells.  In  all  three  portions  there  was  a  lack  of  perfect 
development  of  the  mucosa,  whereas  the  muscular  layers  were  hypertrophied. 

The  cyst  in  the  mediastinum  (Fig.  109,  c)  extended  from  the  third  to  the  tenth 
dorsal  vertebra.  It  was  5.5  cm.  long,  3.7  cm.  in  its  transverse  diameter,  and  4  cm. 
in  thickness.  It  had  thick  walls,  was  opaque,  distended,  and  elastic.  The  tumor 
was  firmly  connected  with  the  vertebral  column.  From  above  downward  it  was 
only  slightly  movable;  from  side  to  side,  somewhat  more  so.  It  lay  to  the  right  of 
the  esophagus. 

The  tumor,  as  shown  in  the  hardened  specimen,  had  produced  much  pressure 
on  the  thoracic  organs.  The  left  lung,  just  behind  and  below  the  hilum,  presented 
a  fiat  surface.  The  right  lung  had  a  deep  groove,  4.3  cm.  long  and  1.5  cm.  broad, 
which  extended  over  the  entire  lower  lobe. 

The  cyst  contained  12  c.c.  of  tenacious,  mucilaginous  fluid,  in  which  cylindric 


INTESTINAL    CYSTS.  185 

cells  and  goblet-cells  were  found.  It  was  divided  into  three  chambers,  which  were 
entirely  separated  from  one  another.  The  walls  showed  an  intestinal  structure, 
but  with  more  marked  development  of  the  muscular  layers,  while  the  mucosa  was 
everywhere  thin  and  in  most  places  devoid  of  folds  or  glands.  Here  and  there, 
however,  were  irregular  folds  between  which  small  glands  opened. 

In  summing  up  the  findings  Roth  says:  "In  the  first  place,  the  intramesenteric 
position  of  the  diverticulum  is  perhaps  unique.  Usually  the  diverticulum  springs 
from  the  convex  surface  of  the  intestinal  canal;  not  infrequently,  however,  it  is 
situated  near  the  mesenteric  attachment.  Interest  is  also  attached  to  the  small 
intestinal  cyst,  which  is  separated  from  the  diverticulum  at  the  matrix;  it  has  the 
same  longitudinal  muscular  layers  and  the  same  serosa."  He  refers  to  the  cyst  as  a 
diverticulum. 

Roth  said  he  knew  of  only  one  similar  case  in  the  literature,  that  of  Raesfeld, 
in  which  the  entire  diverticulum  had  been  transformed  into  a  cyst,  but  in  that  case 
the  cyst  was  seated  on  the  free  circumference  of  the  intestinal  tract. 


A  CYST  OF  THE  CENTRAL  PORTION  OF  THE  OMPHALOMESENTERIC  DUCT. 

Most  of  the  schematic  pictures  illustrating  the  various  points  at  which  remnants 
of  the  omphalomesenteric  duct  may  be  found  represent  cysts  developing  midway 
between  the  intestine  and  the  umbilicus  (Fig.  105,  p.  176).  Theoretically,  one  might 
expect  to  find  them  in  such  a  position,  but  the  following  case,  recorded  by  Schaad,* 
is  the  only  example  of  such  a  condition  that  I  have  found  in  the  literature. 

An  Abdominal  Cyst  Originating  From  a  Remnant 
of  the  Omphalomesenteric  Duct.  —  The  patient  was  a  married 
woman,  thirty-two  years  of  age.  Nothing  is  known  of  the  appearance  of  the  um- 
bilicus at  birth.  She  gave  a  history  of  two  normal  labors.  At  the  last  labor  a 
tumor  was  noted  below  the  umbilicus.  This  patient  was  supposed  to  have  had  a 
severe  inflammation  of  the  bowels  seven  years  previously. 

Several  fingerbreadths  below  the  umbilicus  one  could  feel  an  elastic  tumor 
which  was  sharply  outlined  and  was  the  size  of  a  child's  head.  This  could  be  pushed 
in  all  directions. 

Operation. — A  cyst  the  size  of  a  five-franc  piece  was  found  about  two  finger- 
breadths  below  the  umbilicus,  and  attached  to  the  abdominal  wall  in  the  median 
line.  It  had  been  separated  from  the  peritoneum  and  drawn  out  of  the  abdomen. 
Omental  adhesions  were  tied  off  and  cut.  The  cyst  was  adherent  to  the  appendix. 
The  left  ovary  was  hard  and  atrophic;  the  right  ovary  was  normal.  The  patient 
made  a  good  recovery. 

The  cyst  was  oval  in  form,  7.5  cm.  long,  6  cm.  broad,  and  4.5  cm.  in  thickness. 
Its  walls  varied  from  2  to  4  mm.  in  thickness.  Its  inner  surface  resembled  mucosa 
and  was  light  yellow  in  color,  with  dark  spots.  On  the  right  side  of  the  cyst  was  a 
secondary  cyst,  which  communicated  with  the  larger  one  by  an  opening  the  size  of  a 
pin-head.  The  inner  surface  of  the  cyst  was  smooth,  and  its  walls  were  in  places 
0.5  mm.  thick. 

The  large  cyst  contained  about  200  c.c.  of  a  chocolate-colored,  tenacious  fluid, 
with  an  abundance  of  cholesterin  detritus  and  fat-droplets.     The  smaller  cyst  had 

*  Schaad,  T.:  Ueber  die  Exstirpation  einer  Cyste  des  Dotterganges.  Corr.-Bl.  f.  Schweizer 
Aerzte,  1886,  xvi,  345. 


186  THE    UMBILICUS    AND    ITS    DISEASES. 

similar  but  thicker  contents.  The  wall  of  the  large  cyst  consisted  of  connective 
tissue  and  of  a  large  quantity  of  smooth  muscle  arranged  in  bundles,  which  ran  in 
all  directions.  The  inner  surface  was  lined  with  high  cylindric  epithelium.  Glands 
also  opened  on  the  surface.     The  epithelium  and  glands  were  in  places  missing. 

The  small  cyst  was  lined  with  granulation  tissue,  in  which  were  found  giant- 
cells,  some  containing  20  to  30  nuclei,  arranged  at  the  margin  or  irregularly  scattered 
in  the  center.     [This  rinding  reminds  one  of  foreign-body  giant-cells.] 

Schaad  says  there  is  no  doubt  that  the  cyst  represented  a  remnant  of  the 
omphalomesenteric  duct.  A  portion  of  the  duct  had  remained  open  and  caused 
a  retention  cyst. 

SYMPTOMS  OF  INTESTINAL  CYSTS. 

Some  of  the  children  were  born  dead.  Carwardine's  patient  lived  two  days, 
Roth's  patient  lived  a  year  and  four  months,  and  Kulenkampff's  patient,  three 
years.  In  each  of  these  cases  the  death  was  apparently  due  to  intestinal  obstruc- 
tion. 

Schaad's  patient,  a  woman  of  thirty-two,  recovered.  In  this  case  the  tumor 
apparently  had  no  connection  with  either  the  bowel  or  the  mesentery.  It  was 
removed. 

Fitz  says:  "The  clinical  importance  of  these  intestinal  cysts  obviously  depends 
upon  their  size  arid  situation.  Large  abdominal  cysts  may  interfere  with  the  birth 
of  the  child,  as  in  Hennig's  case  and  in  that  reported  by  Sanger  and  Klopp.  Al- 
though the  actual  cyst  or  cysts  in  each  instance  were  not  the  sole  cause  of  obstructed 
labor,  for  an  associated  ascites  was  present,  they  were  an  important  element. 

"In  Hennig's  case,  puncture  of  the  abdominal  cavity  was  necessary  before  the 
child  could  be  delivered,  and  some  three  liters  of  a  relatively  clear  fluid  escaped. 
The  cyst  was  not  injured.  Even  if  the  child  is  born,  the  cyst  may  remain  as  a 
constant  source  of  danger,  and,  as  in  the  case  reported  by  Roth,  may  prove  fatal 
by  a  twisting  of  its  pedicle.  The  possible  effect  of  an  intrathoracic  cyst  is  shown 
by  this  observer,  who  found  evidence  of  marked  pressure  upon  the  lungs  and  bronchi. 
The  possibility  that  cysts  of  the  abdominal  wall  may  become  of  considerable  size 
is  suggested  by  the  history  of  the  urachus  cysts  sometimes  found  between  the 
muscle  and  peritoneum  and  extending  from  the  navel  to  the  symphysis  pubes." 


TREATMENT. 
If  these  cysts  were  recognized  early  and  before  the  obstruction  was  marked, 
it  would,  of  course,  be  possible  to  remove  those  arising  from  the  free  margins  of 
the  bowel.     Where  the  cyst  is  located  in  the  mesentery,  the  danger  of  injuring 
the  blood-supply  of  the  intestine  would  naturally  materially  increase  the  risk. 


LITERATURE  CONSULTED  ON  INTESTINAL  CYSTS. 

Buchwald:    (Colmers,  Loc.  cib.). 

Carwardine,  T.:  Volvulus  of  Meckel's  Diverticulum.     Brit.  Med.  Jour.,  1897,  ii,  1637. 

Cazin,  H.:  Etude  anatomiquc  et  pathologique  sur  les  diverticules  de  l'intestin.     These  de  Paris, 

1862,  No.  138. 
Colmers,  F.:    Die  Enterokystome  und  ihre  chirurgische  Bedeutung.     Arch.  f.  klin.  Chir.,  1906, 

Ixxix,  132. 


INTESTINAL    CYSTS.  187 

Dittrich:    (Runkel,  Op.  cit.) 

Fitz,  R.  H.:  Persistent  Omphalomesenteric  Remains;  their  Importance  in  the  Causation  of  In- 
testinal Duplication,  Cyst  Formation,  and  Obstruction.  Amer.  Jour.  Med.  Sci.,  1884,  lxxxviii, 
30. 

Hendee:    (Colmers,  Loc.  cit.) 

Hennig,  C:  Cystis  intestinalis,  Cystis  citra  oesophagum  bei  einem  Neugeborenen.  Centralbl. 
f.  Gyn.,  1S80,  iv,  398. 

Huter:    (Runkel,  Op.  cit.) 

Kulenkampff,  D.:  Ein  Fall  von  Enterokystom.  Tod  durch  Darmverschlingung.  Centralbl. 
f .  Chir.,  1883,  x,  679. 

Lohlein:    (Runkel,  Op.  cit.) 

Nasse:    (Runkel,  Loc.  cit.) 

Rimbach:    (Colmers,  Loc.  cit.) 

Roth,  M.:  Ueber  Missbildungen  im  Bereich  des  Ductus  Omphalomesentericus.  Virchows  Arch., 
1881,  Lxxxvi,  371. 

Runkel,  A.:  Ueber  cystische  Dottergangsgeschwulste.     Inaug.  Diss.,  Marburg,  1897. 

Tiedemann:    (Roth,  Loc.  cit.) 

Tscherning:    (Runkel,  Op.  cit.) 

Schaad,  L. :  Ueber  die  Exstirpation  einer  Cyste  des  Dotterganges.  Corr.-Bl.  f.  Schweizer  Aerzte, 
1886,  xvi,  345. 


CHAPTER  X. 
A  PATENT  OMPHALOMESENTERIC  DUCT. 

Historic  sketch. 

Appearance  of  the  umbilicus. 

Condition  of  the  child. 

Treatment. 

Cases  of  patent  omphalomesenteric  duct. 

In  1817  Poussin  reported  the  case  of  a  child  three  years  old.  On  the  fifth  day 
after  birth  the  nurse  made  traction  on  the  cord,  as  it  had  not  yet  come  away. 
"Inflammation"  followed,  and  a  small  opening  developed  at  the  umbilicus.  Some- 
times this  would  close  for  three  weeks  or  more,  but  never  for  a  much  longer  period ; 
from  time  to  time  the  child  passed  round  worms  through  it.  At  the  umbilicus  was 
a  projection  the  size  of  a  hazelnut,  which  showed  at  its  center  an  opening  from 
which  feces  escaped.     The  fistula  was  due  to  a  patent  omphalomesenteric  duct. 

Brun,  in  1834,  published  a  remarkably  clear  article  on  this  subject,  and 
described  several  cases  that  had  been  observed  by  Dupuytren. 

King,  in  1843,  reported  a  case  observed  by  Parsons  and  Gunthorpe.  In  this 
case  a  portion  of  the  small  bowel  had  turned  inside  out  through  the  fistula,  and  lay 
as  a  sausage-like  mass  on  the  abdomen.     This  case  is  reported  in  detail  on  page  233. 

Eves,  in  1845,  reported  the  case  of  a  child,  one  month  old,  who  had  a  red,  fungus- 
like tumor,  about  the  size  and  shape  of  a  raspberry,  attached  to  the  umbilicus.  At 
its  apex  was  a  small  opening,  from  which  occasionally  feculent  liquid  would  issue 
in  jets  and  through  which  a  probe  could  be  passed  directly  backward  for  two  inches. 
On  investigation  it  was  found  that  the  cord  had  separated  at  the  end  of  a  week, 
and  fecal  matter  had  then  commenced  to  come  from  the  umbilicus. 

Schroeder,  in  his  inaugural  dissertation  on  the  formation  of  intestinal  divertic- 
ula, published  in  1854,  said  that  in  the  Pathological  Museum  of  Prague  is  the  record 
of  a  six-months-old  child  who  showed  an  embryonic  omphalomesenteric  duct  which 
passed  from  the  umbilicus  to  the  ileum  as  a  canal  of  gradually  increasing  size. 

Lannelongue  and  Fremont,  in  their  treatise  on  the  varieties  of  congenital 
tumors,  said  that  umbilical  fistulae  of  this  origin  had  been  observed  by  Sandifort, 
F.  Schulze,  Tiedemann,  Ludwig,  and  Tilling. 

A  patent  omphalomesenteric  duct  is  by  no  means  common,  but  Brun  was  able 
to  publish  three  cases  from  Dupuytren's  clinic,  and  Quaet-Faslem  five  cases  from 
Petersen's  clinic.  A  fairly  complete  summary  of  the  cases  scattered  throughout 
the  literature  will  be  found  toward  the  end  of  this  chapter. 

Sex.  —  In  13  of  the  cases  here  recorded  we  have  no  data  as  to  the  sex,  but  of 
the  remaining  35,  31  were  in  males  and  only  4  in  females,  showing  conclusively  that 
the  patent  omphalomesenteric  duct  occurs  almost  exclusively  in  the  male. 

Age.  —  For  the  35  cases  in  which  we  have  data  as  to  the  age  at  which  the 
patient  came  under  observation  we  have  the  following  figures: 

Under  one  year  old 22 

Between  one  and  ten  years  old 8 

From  ten  years  of  age  and  over 5 

188 


A    PATENT    OMPHALOMESENTERIC    DUCT.  189 

Holmes'  patient  and  the  one  observed  by  Leisrink  and  Alsberg  were  ten  years 
old.  Fitz's  patient  was  twenty-one  years  of  age,  and  Kehr's,  twenty-eight  years 
old.     Park's  patient  was  an  athlete,  his  exact  age  not  being  given. 

The  Umbilical  C  o  r  d  .  —  In  many  cases  no  mention  is  made  of  the 
condition  of  the  cord  at  birth,  but  in  quite  a  number  the  records  show  that  the  cord 
was  very  large  at  its  base,  in  some  cases  being  fully  twice  as  thick  as  usual  near  the 
abdomen.  Pratt,  for  instance,  said  that  for  an  inch  and  a  half  from  the  abdomen 
the  cord  was  double  its  usual  thickness.  Many  of  the  cases  were  handled  by  mid- 
wives  and  no  definite  records  made.  I  feel  sure  that  future  reports  will  demon- 
strate that  the  cord  near  the  umbilicus  is  invariably  thicker  than  usual,  when  a 
patent  omphalomesenteric  duct  is  present. 

In  Hansen's  case  the  cord  was  very  large,  bluish  green,  and  abnormally  broad. 
It  came  away  on  the  eighth  day. 

In  the  cases  in  which  the  cord  has  been  very  thick,  as  a  rule,  the  ligature  has 
been  applied  farther  away  from  the  abdomen  than  usual. 


APPEARANCE  OF  THE  UMBILICUS. 

When  the  cord  comes  away,  an  abnormal  condition  at  the  umbilicus  is  generally 
detected  at  once.  The  umbilical  depression  is  occupied  by  a  bright-red  nodule. 
This  may  not  be  larger  than  a  pea,  but  is  frequently  the  size  of  a  hazelnut  (Fig. 
121,  p.  206)  or  of  a  cherry.  In  some  instances  it  is  much  larger.  In  Ardouin's 
case,  for  example,  its  diameter  was  as  large  as  that  of  the  little  finger,  and  the  growth 
was  2.5  cm.  long  (Fig.  115,  p.  192).  In  Hansen's  case  it  was  cylindric,  snout-like, 
and  curved.  On  its  convex  surface  it  was  3  cm.,  and  on  its  under  and  concave 
surface  2  cm.,  in  length.  In  Battle's  case  it  was  l1^  inches  long.  In  Shepherd's 
case  it  looked  like  a  penis  and  was  1}4,  inches  long.  In  Roth's  case  it  formed  a 
cylindric  tumor  2  cm.  in  length  (Fig.  120,  p.  205).  In  Morian's  case,  when  the  cord 
came  away,  a  red,  sausage-like  mass  was  left  (Fig.  119,  p.  202);  in  Deschin's  case 
a  mushroom-shaped  mass  the  size  of  a  walnut  was  found.  Figs.  Ill,  112,  113, 
and  1 14  give  a  very  good  schematic  representation  of  the  various  forms  of  a  patent 
omphalomesenteric  duct. 

In  Jacoby's  case,  when  the  cord  dropped  off,  the  umbilicus  was  occupied  by  a 
raw  area  the  size  of  a  silver  dollar.  In  Quaet-Faslem's  case  of  a  boy,  nine  days  old, 
there  was  a  long,  pear-shaped  tumor,  8  to  10  cm.  in  length.  These  tumors,  whether 
large  or  small,  are  bright  or  dark  red  in  color,  and  are  covered  over  with  typical 
intestinal  mucosa.  This  occasionally,  as  was  noted  in  one  of  Weiss's  cases,  may 
be  covered  over  with  brownish  crusts.  On  examination  of  the  summit  of  the 
tumor,  an  opening  will  be  found.  This  may  be  exceedingly  fine,  or  several  milli- 
meters in  diameter.  A  probe  introduced  into  the  fistula  can  be  passed  directly  into 
the  small  bowel. 

On  microscopic  examination  the  surface  of  the  projection  or  of  the  fistulous 
tract  will  be  found  to  be  covered  with  mucosa  similar  to  that  of  the  small  bowel 
(Fig.  75,  p.  134;  Fig.  123,  p.  207;  Fig.  125,  p.  209). 

In  these  cases  the  omphalomesenteric  duct  has  remained  open,  as  it  was  in  the 
early  months  of  fetal  life  (Fig.  3,  p.  3;  Fig.  5,  p.  5).  Consequently,  the  appear- 
ance of  the  umbilical  growth  after  the  cord  has  come  away  will  depend  on  how  far 
away  from  the  abdomen  the  cord  has  been  ligated.     The  greater  the  amount  of 


190 


THE    UMBILICUS    AND    ITS    DISEASES. 


omphalomesenteric  duct  left  behind,  naturally,  the  longer  will  be  the  protrusion. 
In  those  cases  in  which  a  large,  relatively  flat  area  of  mucosa  is  found,  the  duct  has 
probably  been  present  as  a  cystic  dilatation,  and  this  has  flattened  out  when  the 
cord  ligature  has  cut  through. 

In  this  connection  the  case  observed  by  Prestat  and  cited  by  Ledderhose  is  of 
interest.     In  an  autopsy  on  a  male  infant  at  term,  Prestat  demonstrated  an  intact 


Fig.    111. — A    Patent    Omphalomesenteric    Duct. 
(Schematic.) 
The  lumen  is  of  rather  small  diameter,  and  yet  oc- 
casionally the  bowel  may  prolapse  through  a  lumen  even 
smaller  than  this. 


Polyp 


Fig.  112. — A  Patent  Omphalomesenteric  Duct 
with  a  Polypoid  Formation  at  the  Umbilicus. 
(Schematic.) 

The  lumen  of  the  duct  diminishes  markedly  in  size 
a  short  distance  from  the  small  bowel.  Its  outer  end 
projects  more  than  a  centimeter  beyond  the  surface  of 
the  abdomen.  The  outer  surface  of  this  polypoid  pro- 
jection is  covered  over  with  mucosa,  which  is  directly 
continuous  with  that  lining  the  omphalomesenteric  duct 
and  the  small  bowel. 


Fig.  113. — A  Very  Short  Omphalomesenteric  Duct. 
(Schematic.) 
Usually  the  convex  loop  of  small  bowel  is  several 
centimeters  away  from  the  umbilicus,  but  occasionally, 
when  the  duct  is  very  short,  it  may  be  almost  directly 
attached  to  it.  In  the  sketch  here  shown  the  greater 
part  of  the  duct  lies  in  the  abdominal  wall,  and  in  the 
center  of  the  polypoid  nodule  which  projects  outward 
from  the  umbilical  depression. 


Fig.  114. — A  Patent  Omphalomesenteric  Duct  with 
a  Polyp-like  Formation  at  the  Umbilicus. 
(Schematic.) 

The  omphalomesenteric  duct  is  relatively  short, 
and  at  its  intestinal  end  is  a  sort  of  valve.  Just  above 
the  umbilical  opening  of  the  duct  is  a  polyp  covered  over 
with  intestinal  mucosa  which,  on  the  one  side,  is  con- 
tinuous with  the  skin,  and  on  the  inner  side  with  the 
mucosa  lining  the  omphalomesenteric  duct. 


umbilical  cicatrix.  On  opening  the  abdomen  he  found  a  cord  the  size  of  a  goose- 
quill.  This  was  2J^  inches  long,  and  communicated  with  the  small  bowel.  On 
pressure  fecal  matter  passed  into  the  fistula,  and  at  the  umbilicus  a  small  tumor 
projected  from  the  cicatrix.  This  opened,  and  on  moderate  pressure  fecal  matter 
escaped.  In  this  case  there  was  nearly  a  fistula.  If  the  patent  omphalomesen- 
teric duct  had  extended  just  a  little  farther  out,  it  would  have  been  constricted  by 
the  ligature  and  left  open  when  the  cord  dropped  off. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  191 

The  Discharge  From  the  Fistula.  — ■  This  varies  greatly. 
When  the  opening  is  very  small,  a  little  mucus  may  come  away.  In  some  cases 
this  has  a  fecal  odor;  in  other  cases,  as  in  Salzer's  case,  this  is  lacking. 

Where  the  fistula  is  a  little  larger,  liquid  feces  may  escape  every  day,  or,  as 
noted  in  Pratt's  case,  every  three  or  four  days.  In  some  cases  the  escape  of  feces 
was  detected  only  when  the  child  cried  or  when  pressure  was  made  upon  the  ab- 
domen. In  other  cases  the  bowel  contents  escaped  in  large  quantities  from  the 
umbilicus.  The  amount  of  the  umbilical  discharge  will  depend  almost  entirely 
on  the  size  of  the  fistulous  opening. 

Skin.- — ■  The  skin  around  the  fistula  often  shows  irritation.  This  again  will 
depend  on  the  amount  of  feces  escaping,  and  on  the  irritating  or  non-irritating 
qualities  of  the  contents  of  the  particular  intestine.  Furthermore,  the  nearer  the 
diverticulum  is  to  the  cecum,  the  less  irritation  one  would  expect. 

CONDITION  OF  THE  CHILD. 

In  many  cases  the  children  were  in  good  physical  condition,  but  others  were 
weak  and  frail. 

Billroth's  patient  was  very  weak;  Broadbent's  had  congenital  syphilis;  Mo- 
rian's  child  cried  a  great  deal  and  lost  weight;  Leisrink  and  Alsberg's  patient  fre- 
quently had  abdominal  pain;  Nicaise's  patient  was  pale  and  emaciated,  as  was  also 
one  of  those  observed  by  Quaet-Faslem;  Weiss's  patient  had  had  abdominal  pain, 
diarrhea,  and  vomiting;  Roth's  patient  died  suddenly  when  six  months  old. 

TREATMENT. 

Various  methods  have  been  adopted  to  effect  a  closure  of  the  umbilical  opening. 
The  most  satisfactory  results  have  been  obtained  from  the  use  of  caustics  or  the 
actual  cautery,  or  from  the  application  of  a  ligature  to  the  umbilical  growth. 
Many  of  the  fistulse  closed  permanently;  others  opened  up  again  as  a  result  of 
coughing,  as  in  Weiss's  case.  Leisrink  and  Alsberg's  patient  was  operated  upon 
and  died  of  intestinal  obstruction.  King's  patient  underwent  a  plastic  opera- 
tion, which  successfully  closed  the  umbilical  end  of  the  fistula,  but  the  child  died 
later  of  intestinal  obstruction. 

Removal  of  the  umbilicus  and  the  fistulous  tract  has  given  the  best  permanent 
results.  This  is  the  only  method  to  be  considered  at  the  present  day.  An  incision 
should  be  made  encircling  the  umbilicus  down  to  and  through  the  peritoneum; 
if  traction  is  then  made,  the  fistula  and  the  loop  of  small  bowel  can  be  readily  brought 
out  of  the  abdomen.  The  fistula  should  then  be  removed  in  precisely  the  same 
manner  as  in  dealing  with  an  appendix. 

CASES  OF  PATENT  OMPHALOMESENTERIC  DUCT. 
Other  cases  of  patent  omphalomesenteric  duct  are  referred  to  in  Chapter  XI 
(p.  214),  on  Prolapsus  of  the  Bowel  Through  a  Patent  Omphalomesenteric  Duct;  and 
"in  Chapter  XXI  (p.  328),  on  Worms. 

Radical  Operation  in  a  Case  of  Persistent  Omphalo- 
mesenteric    Duct.  —  Alsberg's  *  patient  was  eighteen  weeks  old.     When 

*  Alsberg,  A. :  Ueber  einen  Fall  von  Radicaloperation  eines  persist irenden  Ductus  omphalo- 
meseraicus.     Deutsche  med.  Wochenschr.,  1892,  xviii,  1040. 


192 


THE    UMBILICUS    AND    ITS    DISEASES. 


the  cord  came  away,  healing  did  not  occur,  a  red,  moist  area  remaining.  This 
became  more  prominent,  and  a  small,  horn-like  projection,  1  cm.  long,  developed. 
This  projection  was  red  in  color  and  had  an  opening  from  which,  yellow  fluid 
escaped. 

On  admission  the  child  was  found  to  be  well  developed.  At  the  umbilicus  was  a 
flat  tumor,  the  size  of  a  bean,  with  an  abundance  of  fluid  escaping  from  an  opening 
in  it.  The  line  of  junction  between  the  skin  and  mucosa  was  sharp.  A  bougie 
could  be  passed  for  20  cm.  into  the  opening. 

Operation. — -The  omphalomesenteric  duct  was  cut  off  near  the  small  bowel  and 
the  stump  turned  in.     The  child  died  on  the  twelfth  day  from  peritonitis. 

Patent  Omphalomesenteric  Duct.  Extirpation.  Re- 
covery.* —  The  child  was  born  September  14,  1906,  and  was  seen  on  October 

5th.  He  was  then  twenty-one  days  old,  and  pre- 
sented a  fecal  fistula  at  the  umbilicus.  The  parents 
thought  that  the  woman,  who  had  had  charge  of  the 
tying  of  the  cord,  had  applied  this  ligature  to  an  in- 
testinal loop,  but  the  history  shows  that  there  was 
no  room  for  criticism  of  the  midwife.  The  boy  was 
well  nourished. 

At  birth  the  person  who  tied  the  cord,  5  or  6  cm. 
from  the  umbilicus,  noted  that  it  was  large  at  its  base. 
In  the  course  of  three  days  the  cord  came  away,  and 
in  its  place  was  a  tumor  the  size  of  a  little  finger  in 
diameter,  and  2.5  cm.  in  length.  It  was  red  in  color, 
and  from  it  a  few  days  later  there  was  a  considerable 
amount  of  hemorrhage. 

On  October  1st,  the  sixteenth  day,  the  family 
noticed  for  the  first  time  an  escape  of  intestinal  ma- 
terial and  gas.  At  the  same  time  the  bowels  moved 
regularly. 

Ardouin  saw  the  child  five  days  later,  and  the 
tumor  presented  the  picture  seen  in  Fig.  115.  It  was 
red,  like  a  cherry,  and  resembled  intestinal  mucosa 
which  had  been  irritated.  The  tumor  was  limited  at 
its  base  by  a  cutaneous  elevation  at  the  umbilicus.  The  surrounding  skin  was  red- 
dened and  ulcerated  at  some  points.  At  the  summit  of  the  tumor  was  a  depression, 
from  which  fecal  material  and  gas  escaped.  Ardouin  recognized  the  condition  as 
one  of  persistent  omphalomesenteric  duct.     There  were  no  other  malformations. 

Operation. — A  lozenge-shaped  incision  encircling  the  umbilicus  was  made  and 
the  peritoneum  opened.  The  tract  was  clamped  off  at  the  point  of  junction  with 
the  intestine,  and  cut  across  with  the  thermocautery,  just  as  in  the  removal  of  an 
appendix.  The  opening  in  the  bowel  was  closed,  and  the  child  made  a  perfect 
recovery. 

Extroversion  of  Meckel's  Diverticulum.  —  Battle's  f 
patient  was  a  girl  eighteen  months  old.     She  was  fairly  well  nourished,  but  had 

*  Ardouin,  P.:  Persistance  du  Diverticule  de  Meckel  ouvert  a  l'ombilic.  Fistule  stercorale. 
Omphalectomie.     Extirpation  du  diverticule,  guerison.     Arch.  prov.  de  chir.,  Paris,  1908,  xvii,  1. 
t  Battle,  W.  H.:   Clin.  Soc.  Trans.,  London,  1893,  xxvi,  237. 


Fig.  115. — A  Patext  Omphalomes- 
enteric Duct.  (After  Ardouin.) 
A  probe  has  been  introduced  into 
the  tract  in  order  to  show  its  permea- 
bility. 1,  the  diverticulum;  2,  the 
umbilicus;  3,  the  surrounding  collar 
of  skin;  4,  the  point  of  attachment  of 
the  diverticulum  to  the  intestine;  5, 
the  probe  passing  through  the  length 
of  the  fistulous  tract. 


A    PATENT    OMPHALOMESENTERIC    DUCT. 


193 


a  pear-shaped  tumor  at  the  umbilicus.     This  was  noted  shortly  after  birth,  and 
had  been  increasing  in  size. 

It  was  one  and  a  half  inches  long,  and  covered  with  red,  smooth  mucosa,  which 
bled  on  manipulation.  There  was  a  sharp  line  of  demarcation  between  the  tumor 
and  the  skin.  At  the  free  end  the  diameter  equaled  that  of  a  cherry,  and  at  its 
narrowest  point  was  reduced  by  one-half.  At  its  extremity  was  a  hole  through 
which  a  probe  could  be  passed  inward  for  two  inches.  There  was  a  thin,  rather 
feculent  discharge,  and  the  tissues  surrounding  the  tumor  were  eczematous.  The 
stools  were  normal.  The  protrusion  could  be  reduced  only  very  slightly  by 
pressure.     It  increased  in  size  when  the  patient  cried  or  stood  erect. 

Operation. — The  abdomen  was  opened;    the  diverticulum  was  cut  through 
transversely,  and  the  stump  invag- 
inated.     The  next  day  scarlet  fever 
developed,  and  the  child  died  on  the 
eleventh  day. 

At  autopsy  the  abdominal  con- 
dition was  found  to  be  perfectly  nor- 
mal. The  death  was  due  to  scarlet- 
fever.  The  distance  of  the  divertic- 
ulum from  the  ileocecal  valve  was 
ten  inches. 

A  Patent  Omphalo- 
mesenteric Duct.*  —  The 
boy,  fourteen  weeks  old,  had  had  a 
fecal  umbilical  fistula  since  birth. 
Projecting  from  the  umbilicus  was 
a  growth  half  an  inch  in  length  from 
which  a  small  amount  of  fecal  matter 
escaped  from  time  to  time.  Billroth 
thought  that  this  represented  an 
omphalomesenteric  duct  that  had 
remained  open  (Fig.  116). 

The  growth  was  tied  off  with  the 
hope  that  the  fistula  might  close,  but  when  the  suture  came  away,  it  remained 
open.     Billroth  thought  of  closing  the  fistula  later  with  sutures,  but  the  child  was 
very  weak,  and  was  taken  home  by  its  parents.     It  soon  died. 

A  Patent  Vitelline  Duct.  —  Broadbent  f  showed  the  specimen. 
The  child  had  occasionally  passed  fecal  matter  from  the  umbilicus,  but  as  it  was  a 
subject  of  congenital  syphilis,  no  surgical  procedure  was  undertaken.  At  autopsy 
a  coil  of  intestine  was  found  in  contact  with  the  umbilicus,  and  there  was  a  slender 
tube  passing  from  the  intestine  to  it. 

A  Patent  Meckel's  Diverticulum. J  —  A  boy,  six  months  old, 
was  brought  to  the  hospital  June  3,  1894.  He  had  a  pear-shaped  tumor  4  cm. 
long,  with  a  pedicle  about  1  cm.  in  diameter,  at  the  umbilicus.     Its  surface  was 


Fig.  116. — A  Patent  Omphalomesenteric  Duct.  (After 
Billroth.) 
The  patient  was  a  boy,  fourteen  weeks  old,  who  had  had 
an  umbilical  fecal  fistula  since  birth.  Projecting  from  the  um- 
bilicus was  a  growth,  half  an  inch  in  length,  from  which  a 
small  amount  of  fecal  matter  escaped  from  time  to  time. 


*  Billroth:  Chirurgische  Klinik,  Berlin,  1869,  294. 
f  Broadbent:   Med.  Times  and  Gaz.,  1866,  ii,  45. 

JBroca:    Persistance  du  diverticule  de  Meckel  ouvert  a  l'ombilic  et  invagine  au  dehors. 
Revue  d'orthopedie,  1895,  vi,  47. 
14 


194  THE    UMBILICUS    AND    ITS    DISEASES. 

covered  with  a  bright-red  mucosa,  resembling  that  of  a  prolapsed  rectum.  In 
the  center  was  an  orifice  from  which  there  escaped  a  mucous  liquid.  Nothing  re- 
sembling fecal  matter  had  ever  been  noted.  A  probe  was  easily  introduced  into 
the  center  of  the  orifice,  and  passed  into  the  abdomen. 

Operation,  June  9,  1894. — Broca  made  a  circular  incision  around  the  umbilicus, 
going  down  to  the  peritoneum.  The  growth  communicated  with  the  intestine  by 
an  opening  that  would  admit  a  probe.  The  opening  in  the  ileum  was  closed,  and 
the  child  made  a  good  recovery. 

Patent  Omphalomesenteric  Duct.  —  Bureau  records  another 
observation  made  by  Broca.*  A  boy,  aged  ten  months,  was  admitted  to  the 
hospital  on  October  21,  1897.  In  the  center  of  the  umbilicus  was  a  small  red  tumor, 
about  2  cm.  long,  consisting  of  the  everted  diverticular  mucosa.  At  its  summit 
was  an  orifice  into  which  a  probe  could  be  passed.  There  was  a  serous  discharge 
from  the  fistula.  On  October  21st  the  fistulous  tract  was  resected.  The  child 
made  a  good  recovery. 

Prolapsus  of  the  Omphalomesenteric  Duct.  —  Bureau  f 
says  that  diverticular  entero-umbilical  fistulse  are  always  due  to  the  persistence 
of  Meckel's  diverticulum  or  to  remains  of  the  omphalomesenteric  duct.  Open 
diverticula  at  the  umbilicus  are  rare,  and  prolapsus  of  the  diverticulum  complicating 
the  fistula  is  still  rarer.  Broca  observed  one  case  in  12,000  patients  examined  at 
the  Hopital  Trousseau  during  two  years.  J  The  danger  is  from  intestinal  occlusion. 
The  modes  of  treatment  are  compression,  ligation,  cauterization;  laparotomy 
followed  by  resection  of  the  diverticulum  and  closure  of  the  bowel  should  be 
employed. 

Patent  Omphalomesenteric  Ducts.  —  Brun's  §  article,  pub- 
lished in  1834,  is  a  remarkably  clear  one.  He  records  three  cases  coming  under  the 
care  of  Dupuytren  and  a  fourth  observed  by  Poussin.  In  three  of  the  four  cases 
there  was  an  umbilical  fecal  fistula,  and  in  the  other  there  was  no  fistula.  Brun 
said  that  Dupuytren  had  never  seen  a  case  before  1833,  and  then  in  short  succession 
the  three  patients  were  admitted. 

C  a  s  e  1  came  under  Dupuytren's  care.  The  child  was  twenty-eight  days  old. 
At  the  umbilicus  was  a  tumor  the  size  of  a  cherry,  red,  and  covered  over  with 
mucosa.  The  tumor  was  irreducible;  it  was  narrowed  at  its  base  and  had  a  per- 
foration in  its  center  from  which  fecal  matter  escaped.  In  this  case  the  cord  had 
dropped  off  on  the  fifth  or  sixth  day,  and  shortly  afterward  the  condition  had  been 
noted.  The  child's  general  health  was  good.  A  sound  could  be  carried  one  and  a 
half  inches  into  the  fistula.  Finally  the  growth  was  tied  off  with  a  silk  ligature.  It 
sloughed  off  after  fifty-four  hours  and  the  wound  healed. 

C  a  s  e  3.  A  boy,  who  came  under  Dupuytren's  care,  had  a  large  cord  at  birth. 
This  was  tied  at  a  point  five  fingerbreadths  from  the  umbilicus.  At  the  end 
of  the  fifth  day  the  cord  had  not  yet  come  away,  and  a  new  ligature  was 
applied  nearer  to  the  abdomen.  On  the  ninth  day,  when  the  cord  sloughed 
off,    there   were   two   small   red   tumors   at   the   umbilicus.     These   were  about 

*  Broca  (Quoted  by  Bureau):  These  de  Paris,  1898,  No.  257,  32. 

t  Bureau,  J. :  Prolapsus  ombilical  du  diverticule  de  Meckel.  These  de  Paris,  1898,  No.  257, 
14. 

%  Broca:    Rev.  d'orthopeYlie,  1895. 

§  Brun,  L.  A.:  Sur  une  espece  particuliere  de  tumeur  fistuleuse  stercorale  de  l'ombilic. 
These  de  Paris,  1834,  No.  238. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  195 

the  size  of  a  finger-tip,  and  projected  half  an  inch.  They  were  roundish  and 
covered  over  with  mucosa.  The  one  was  opposite  the  other,  and  both  were  in  the 
same  horizontal  plane.  The  right  was  smaller  than  the  left.  The  left  one  was 
perforated  in  its  center,  having  an  opening  one  ligne  (2.25  mm.)  in  diameter.  A 
probe  could  be  carried  for  more  than  an  inch  into  this  opening,  and  fecal  matter 
escaped  from  it.  The  child  also  had  normal  stools.  Neither  of  the  tumors  was 
reducible  on  pressure.  Both  were  tied  with  silk  and  dropped  off  on  the  third 
day,  with  perfectly  satisfactory  results,  the  fistula  remaining  closed. 

A  Patent  Omphalomesenteric  Duct.*  —  Deschin's  patient 
was  a  boy  five  months  old.  A  tumor  was  noted  at  the  umbilicus  when  the  cord 
came  away.  To  the  left  of  the  umbilicus  was  a  walnut-sized,  mushroom-like  tumor, 
bright  red  in  color,  and  reminding  one  of  the  mucosa  of  the  large  bowel.  In  the 
middle  was  an  opening  which  led  into  the  bowel.  Feces  escaped  from  it.  The 
surface  of  the  growth  was  alkaline  in  reaction. 

The  abdomen  was  opened,  and  the  fistulous  tract  found  to  be  3  to  4  cm.  long. 
It  passed  to  the  small  bowel.  The  tract,  together  with  the  umbilicus,  was  removed. 
The  child  took  the  anesthetic  badly  and  died  several  hours  later.  At  autopsy  it 
was  found  that  the  fistula  was  49  cm.  above  the  cecum.  It  was  lined  with  intestinal 
mucosa. 

A  Case  of  Diverticulum  Ilei  Communicating  with 
the  Umbilicus. f  —  W.  D.,  aged  one  month  and  four  days,  had  a  red, 
fungus-like  tumor,  about  the  size  and  shape  of  a  raspberry,  attached  at  the  umbilicus. 
At  its  apex  was  a  small  opening  from  which  occasionally  feculent  liquid  would  issue 
in  jets  and  through  which  a  probe  passed  directly  backward  for  two  inches.  The 
child  was  in  good  health  and  the  bowels  moved  in  a  natural  way. 

On  investigation  it  was  found  that  the  cord  had  separated  at  the  end  of  a  week, 
and  fecal  matter  had  then  commenced  to  come  from  the  umbilicus. 

A  ligature  was  tied  firmly  around  the  base  of  the  umbilical  projection.  This 
sloughed  off  in  a  few  days.  The  canal  became  obliterated,  and  the  discharge  ceased 
completely.  Eves  refers  to  his  case  as  one  particularly  favorable  for  palliative 
treatment. 

Intestinal  Obstruction  Due  to  a  Patent  Omphalo- 
mesenteric Duct.  —  Fitz  J  refers  to  a  case  observed  by  Dr.  John  Homans, 
of  Boston.  A  man,  twenty-one  years  of  age,  met  with  a  severe  fall  February  8, 
1884.  He  had  always  been  healthy,  with  the  exception  of  a  congenital  umbilical 
sinus,  which  was  vaguely  supposed  to  communicate  with  the  intestine.  His 
mother  was  confident  that  portions  of  food  (seeds  and  the  like),  after  being  swal- 
lowed, had  escaped  at  times  from  the  sinus,  and  that  the  latter  had  been  closed 
since  October,  1882. 

"Four  days  after  the  fall  he  was  seen  by  Dr.  John  0.  Dow,  of  Reading,  Mass., 
who  found  him  suffering  from  absolute  intestinal  obstruction,  tympanites,  tender- 
ness, and  pain.  Three  days  later — a  week  after  the  accident — frequent  vomiting 
of  an  offensive,  so-called  fecal,  material  took  place.     Dr.  Homans  was  summoned 

*  Deschin:  Zur  Frage  der  chirurgischen  Behandlung  bei  dem  Vorfall  des  Dotterganges. 
Centralbl.  f.  Chir.,  1895,  xxii,  1154. 

t  Eves,  A:  The  Lancet,  London,  1845,  i,  101. 

t  Fitz,  R.:  Persistent  Omphalomesenteric  Remains,  their  Importance  in  the  Causation  of  In- 
testinal Duplication,  Cyst-formation  and  Obstruction.     Amer.  Jour.  Med.  Sci.,  1884,  lxxxviii,  30. 


196  THE    UMBILICUS    AND    ITS    DISEASES. 

in  consultation,  after  another  interval  of  three  days,  and  found  the  patient  vom- 
iting, every  few  minutes,  an  exceedingly  offensive  brown  fluid.  The  abdomen  was 
distended,  tympanitic,  and  tender.  The  eyes  were  bright,  and  the  countenance 
intelligent.     Pulse  feeble,  about  130. 

"A  dark-colored  urine  was  drawn  from  the  bladder  and  a  director  introduced 
into  the  sinus.  A  little  fecal  matter  seemed  to  escape.  The  opening  was  enlarged 
laterally,  especially  to  the  left,  sufficiently  to  admit  the  finger.  The  incision  may 
have  been  an  inch  and  a  half  long,  and  the  finger  entered  the  peritoneal  cavity. 
No  obstruction  was  felt  near  the  umbilicus  within  reach  of  the  finger.  A  loop  of 
intestine  was  seized,  sewn  to  the  skin,  and  an  opening,  about  half  an  inch  in  length, 
was  made  through  its  wall.  No  fecal  or  intestinal  contents  escaped  until  after  the 
junction  was  completed,  when  an  offensive,  brownish  fluid  material  and  gas  were 
freely  discharged. 

"On  the  day  following  the  operation  the  temperature  was  100.4°  F.;  the  pulse, 
108.  The  vomiting  had  ceased,  and  there  was  some  relish  for  food.  Occasional 
twinges  of  pain  in  the  right  groin  were  complained  of.  There  was  but  little  ab- 
dominal distention,  and  Dr.  Dow  was  able  to  detect  a  circumscribed  enlargement 
in  the  vicinity  of  the  ileocecal  valve.  Two  days  later  the  temperature  was  normal; 
pulse,  108.  The  swelling  and  tenderness  in  the  groin  were  much  diminished,  and 
there  were  no  twinges  of  pain.  Solid  food  was  desired.  On  the  next  day  the  tem- 
perature was  96.2°  F.,  pulse,  120.  Restlessness,  distress  in  the  back,  and  ringing 
in  the  ears  were  the  prominent  symptoms,  and  were  attributed  to  insufficient  nour- 
ishment. Injections  of  beef-tea  were  given,  and  were  followed  by  marked  relief, 
the  pulse  falling  to  108  and  the  temperature  rising  to  normal.  His  strength 
gradually  failed,  however,  notwithstanding  that  food  was  given  by  the  mouth  and 
rectum.  The  temperature  became  persistently  lower,  and  the  pulse  weaker,  with 
increasing  frequency.  His  death  took  place  one  week  after  the  operation.  On 
the  day  preceding  a  passage  from  the  bowels  occurred,  although  Dr.  Dow  was  of 
the  opinion  that  the  contents  of  the  stomach  never  passed  beyond  the  intestinal 
fistula. 

"An  autopsy  was  made  twenty-six  hours  after  death  by  Dr.  G.  E.  Putney,  of 
Reading,  who  has  furnished  the  following  interesting  report : 

"He  found  the  body  considerably  emaciated  and  the  abdomen  flat.  A  probe 
inserted  into  the  congenital  opening  passed  downward,  forward,  and  to  the  right, 
at  an  angle  of  40  degrees  with  the  median  line. 

"The  parietal  peritoneum  was  glistening,  of  a  dark,  reddish-slate  color.  Its 
blood-vessels  were  prominent,  especially  around  the  umbilicus,  within  a  radius  of 
four  inches.  There  was  no  lymph.  The  small  intestine  was  of  a  very  dark,  drab- 
red  color.  The  large  intestine  and  the  colon  were  of  about  two-thirds  the  normal 
size.  The  artificial  opening  into  the  intestine  was  52  inches  below  the  pylorus. 
Its  edges  were  thickened,  ragged,  and  sloughing,  and  had  failed  to  unite  with  those 
of  the  abdominal  wound. 

"A  diverticulum  four  inches  long  and  half  an  inch  in  diameter  arose  from  the  ileum 
four  feet  above  the  ileocecal  valve,  and  extended  to  the  umbilicus.  The  ileum 
below  its  origin  was  three-quarters  of  an  inch  in  diameter.  The  tissues  of  the 
diverticulum  appeared  normal,  with  the  exception  of  the  muscular  coat  of  the  distal 
three-quarters  of  an  inch,  which  was  thrice  the  normal  thickness.  A  tendinous 
cord  the  size  of  a  darning  needle  and  4  inches  long  proceeded  from  the  mesentery 


A    PATENT    OMPHALOMESENTERIC    DUCT. 


197 


along  the  diverticulum  and  became  lost  in  the  tissue  surrounding  the  umbilical 
opening.     In  its  course  along  the  diverticulum  it  appeared  as  if  ensheathed. 

"The  contents  of  the  small  intestine  resembled  dark  pea-soup;  those  of  the 
large  intestine  were  pultaceous,  resembling  yeast.  There  was  no  evidence  of  any 
existing  constriction  at  the  time  of  autopsy. 

"There  seems  to  be  no  reasonable  doubt  that  the  above  case  is  one  of  intestinal 
obstruction  from  persistent  omphalomesenteric  remains.  The  autopsy  gives  no 
evidence  of  the  manner  in  which  the  obstruction  occurred." 

Fitz's  article  is  one  of  the  most  readable  in  the  English  language. 
A    Patent    Omphalomesenteric    Duct.*  — ■  The  boy  was  five 

years  old.  When  the  cord  came  away,  an 
enlargement  the  size  of  a  hazelnut  was 
noted  at  the  umbilicus.  This  nodule  was 
red  and  discharged  a  clear  liquid,  which  at 
times  was  blood-tinged.  Up  to  the  fifth 
year  the  tumor  had  occasioned  no  serious 


Fig.  117. — A  Patent  Omphalomesenteric  Duct. 
(After  Froelich.) 
The  umbilicus  was  particularly  prominent,  ow- 
ing to  a  definite  projection.  This  had  existed  since 
the  cord  came  away.  For  its  relative  size  and  posi- 
tion see  Fig.  118. 


Fig.  118. — A  Patent  Omphalomesenteric  Duct.  (After 
Froelich.) 
The  umbilical  growth  seen  in  Fig.  117.  S,  S,  is  the  sound, 
which  passed  down  a  certain  distance  and  then  directly  into 
the  abdomen,  as  indicated  by  the  dotted  line.  The  entire 
growth  was  removed.  Its  inner  portion  was  continuous  with 
a  pervious  cord  which  opened  into  a  loop  of  small  bowel. 


trouble.  When  the  child  came  under  observation,  an  elongated  projection  was 
noted  at  the  umbilicus  (Fig.  117).  At  its  center  was  an  opening  from  which  a  clear 
liquid  escaped.  The  tumor  was  bright  red  and  resembled  intestinal  mucosa.  It 
was  soft  in  consistence,  but  on  pressure  could  not  be  reduced  in  size.  The  patient's 
movements  did  not  cause  any  alteration  in  its  size.  A  probe  introduced  into  this 
fistula  could  be  carried  downward  and  came  in  contact  with  the  lower  part  of  the 
mass,  but  a  curved  probe  directed  toward  the  umbilicus  passed  into  the  abdomen. 
The  fluid  escaping  was  alkaline.  The  condition  was  one  of  patent  omphalomesen- 
teric duct  with  partial  eversion  of  the  outer  portion. 


*  Froelich,  R. :    Du  fungus  ombilical  du  nouveau-ne,  a  l'occasion  cl'une  operation  de  prolap- 
sus ombilical  du  diverticule  de  Meckel.   Rev.  mens,  des  maladies  de  l'enfance,  Paris,  1902,  xx,  517. 


198  THE    UMBILICUS    AND    ITS    DISEASES. 

The  omphalomesenteric  duct  was  excised  from  a  point  about  0.5  cm.  from  the 
intestine,  and  the  stump  turned  into  the  bowel.  Microscopic  examination  showed 
that  the  surface  of  the  umbilical  nodule  was  covered  with  intestinal  mucosa. 

A  Patent  Omphalomesenteric  Duct.*  —  The  patient  was  a 
boy  two  and  one-half  years  old.  From  the  time  that  the  cord  had  come  away  fecal 
matter  had  been  noted  at  the  umbilicus.  In  time  a  granular  tumor  the  size  of  a 
cherry  developed  at  this  point.  There  was  some  prolapse  of  the  mucosa  of  the  fis- 
tulous tract. 

The  fistulous  tract  was  dissected  free  as  far  as  the  bowel  and  then  removed. 
The  patient  made  a  good  recovery. 

A  Patent  Omphalomesenteric  Duct.f  —  At  birth  the  cord 
was  very  large  near  the  umbilicus.  It  was  bluish-green  in  color,  and  fell  off  on  the 
eighth  day.  There  remained  a  red,  snout-like  mass,  2  cm.  in  length.  This 
secreted  much  pus,  and,  when  the  child  cried,  there  was  some  bleeding.  Later 
on  gas-bubbles  and  feces  escaped. 

At  examination  there  was  noted  at  the  umbilicus  a  cylindric,  somewhat  conic, 
snout-like  mass,  which  hung  downward  and  to  the  left.  The  left,  which  was  the 
under  side,  was  2  cm.  long.  The  right,  the  upper  side,  was  3  cm.  long.  At  the 
bottom  the  growth  was  2  cm.  in  diameter. 

The  skin  was  drawn  upward  upon  the  surface  of  the  tumor  on  the  right  side  for 
a  distance  of  1.5  cm.;  on  the  left  for  a  distance  of  0.75  cm.  The  remainder  of  the 
tumor  was  covered  with  bright-red  mucosa.  In  the  center  was  a  funnel-shaped 
opening.     A  sound  passed  upward  and  to  the  right  7  cm. 

Operation. — Two  threads  having  been  passed  through  its  base  to  prevent 
its  giving  way,  the  tumor  was  excised.  Three  small  vessels  were  caught.  On 
account  of  the  friable  mucosa  it  was  impossible  to  suture  it,  and  the  stitches  were 
taken  at  some  distance  away.  The  peritoneum  was  not  seen.  The  skin  ring  of 
the  umbilicus  was  removed,  and  this  area  was  drawn  over  the  stump  and  closed. 
The  child  made  a  good  recovery.  The  wound  healed  perfectly,  and  the  umbilical 
ring,  which  was  previously  2.5  cm.  in  diameter,  contracted  down  until  it  was  very 
small. 

The  microscopic  picture  showed  typical  intestinal  mucosa.  The  condition  was 
due  to  a  patent  omphalomesenteric  duct. 

A  Fecal  Concretion  Discharged  at  the  Umbilicus. J  — 
Heaton  presented  a  patient  in  whom,  after  a  short  illness,  a  large  fecal  concretion 
had  been  discharged  from  the  umbilicus.  This  patient,  before  his  illness  and  since 
he  left  the  hospital,  had  been  in  perfect  health.  There  was  no  history  nor  any 
evidence  of  tuberculosis.  Heaton  suggested  that  perhaps  a  concretion  had  become 
impacted  in  Meckel's  diverticulum,  had  set  up  an  ulceration  there,  and,  for- 
tunately for  the  patient,  had  been  discharged  from  the  umbilicus. 

Probable  Persistence  of  the  Omphalomesenteric 
Duct.f  —  The  patient  was  a  female  child,  four  months  old,  who  had  a  red, 
velvety,  cylindric  projection  at  the  umbilicus.     This  was  three-quarters  of  an  inch 

*  Gevaert,  G.:    Fistule  ombilicale  diverticulaire  chez  un  enfant.    Ann.  de  med.  et  de  chir., 
-   iv,  1. 
f  Hansen,  J.  A. :   Ein  Beitrag  zur  Persistenz  des  Ductus  omphalo-entericus.  Inaug.  Diss., 
Kiel  I      " 

%  Heaton,  G.:  Brit,  Med.  Jour.,  1898,  i,  627. 

§  Hickman:  Persistent  Vitelline  Duct,  Trans.  Path.  Soc.  London,  1869,  xx,  418. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  199 

long,  stiff  and  tense,  and  constricted  at  its  base.  Its  end  was  covered  with  a  thin 
slough.  It  bled  readily,  but  no  aperture  could  be  detected.  It  had  existed  since 
the  cord  had  come  away.  The  mother  said  she  had  noticed  a  little  moisture  having 
the  odor  of  feces,  but  no  fecal  matter  could  be  detected. 

Hickman  says  that  usually,  in  these  cases,  eversion  of  the  mucous  membrane 
leaves  a  canal  extending  into  the  bowel  through  which  the  feces  occasionally  pass. 
In  this  case  no  canal  could  be  found. 

[The  fact  that  there  was  a  fecal  odor  here  seems  to  indicate  clearly  that  an  open- 
ing existed,  although  Hickman  did  not  find  it.  A  reference  to  other  cases  will  show 
that,  although  no  definite  connection  with  the  bowel  was  detected,  at  operation 
the  canal  was  found  to  be  patent.] 

Patent  Omphalomesenteric  Duct.  —  Holmes*  had  a  patient 
who  gave  a  history  of  having  had  a  warty  growth  at  the  umbilicus  during  his  first 
year.  This  was  ligated.  Holmes  saw  him  when  he  was  ten  years  old,  and  at  that 
time  he  had  a  constant  but  not  copious  discharge  from  the  umbilicus.  This  fluid, 
macroscopically  and  chemically,  resembled  bile.  Later  vegetable  matter  escaped, 
showing  that  a  definite  fecal  fistula  existed. 

A  Patent  Omphalomesenteric  Duct,  f  —  The  patient  was 
a  poorly  developed  male.  The  midwife,  when  tying  the  cord,  noticed  its  unusual 
breadth,  but  nevertheless  put  the  ligature  at  the  usual  point.  When  the  cord 
dropped  off  on  the  third  day  there  was  left  a  raw  area,  the  size  of  a  thaler,  which 
was  prominent  and  moist  and  from  which  fluid  escaped.  Within  a  few  days  the 
surrounding  parts  became  erythematous,  and  on  the  sixth  day  the  mother  observed 
feces  coming  from  the  umbilicus.  The  greater  part  of  the  intestinal  contents, 
however,  still  passed  by  the  rectum.  The  child  had  no  pain  in  the  lower  abdomen, 
but  the  parents  were  greatly  distressed. 

After  several  physicians  had  treated  the  child  without  success,  an  old  nurse 
put  on  an  occlusion  apparatus  and  then  applied  pressure.  As  a  result  the  feces 
were  held  back  and  the  ring  closed  rapidly  and  became  flatter.  By  the  sixth  week 
the  child  had  improved  greatly  and  soon  only  a  small  amount  of  feces  escaped 
from  the  umbilicus.  Three  or  four  weeks  later  the  umbilicus  had  healed  com- 
pletely and  the  child  was  strong  and  healthy. 

A  Patent  Omphalomesenteric  Duct.J  —  The  patient  was  a 
man,  twenty-eight  years  old,  who  had  a  patent  omphalomesenteric  duct.  At  the 
umbilicus  was  a  reddish  mass,  the  size  of  a  cherry,  showing  at  its  top  a  depression 
from  which  a  mucous  secretion  escaped;  no  feces,  however,  were  noted.  The  patient 
had  suffered  from  obstipation,  and  felt  as  if  there  were  something  in  the  umbilical 
region  which  prevented  the  feces  from  passing.  He  had  had  severe  colic.  On 
account  of  the  foul  odor  his  comrades  avoided  him,  and  his  condition  had  rendered 
him  melancholic. 

Operation. — The  duct  was  removed  at  the  bowel  and  the  opening  in  the  ileum 
closed  with  two  rows  of  sutures.  The  patient  made  a  good  recovery,  but  three 
weeks  after  operation  he  committed  suicide  at  his  home. 

*  Holmes,  T. :  Surgical  Treatment  of  Diseases  of  Children,  London,  1868,  181. 

t  Jacoby,  M.:  Zur  Casuistik  der  Nabelfisteln.  Berlin,  klin.  Wochenschr.,  1877,  xiv,  202. 
Jacoby  also  reported  this  case  in  Jahrb.  f.  Kinderheilk.  u.  phys.  Erzieh.,  1878,  xii,  144. 

X  Kehr,  H. :  Ueber  einen  Fall  von  Radicaloperation  eines  persistirenden  Ductus  Omphalo- 
meseraicus.     Deutsche  med.  Wochenschr.,  1892,  xviii,  1166. 


200  THE    UMBILICUS    AXD    ITS    DISEASES. 

A  Patent  Omphalomesenteric  Duet.*  —  The  child  was  six 
months  old.  At  the  umbilicus  was  a  red,  smooth,  moist  tumor,  the  size  of  a  hazel- 
nut. When  the  child  cried  or  when  pressure  was  made  on  the  abdomen,  the  tumor 
increased  in  size.  At  its  most  prominent  part  was  an  opening,  hardly  the  size  of  a 
linseed,  into  which  a  sound  could  be  introduced  for  from  5  to  8  cm.  There  escaped 
from  the  fistula  a  clear  green  fluid,  with  a  slightly  yellowish  tint.  Under  light  nar- 
cosis the  surface  was  seared  with  the  cautery  and  a  bandage  was  applied.  At  the 
end  of  eight  days  nothing  but  a  small  opening  remained.  It  was  suggested  that 
the  child  be  taken  home  for  a  time.  When  Kern  reported  the  case,  the  child  was 
more  than  one  year  old  and  had  improved,  but  a  fistula  remained. 

Operation.- — Professor  Kraske  later  excised  the  diverticulum  and  the  child  made 
a  good  recovery. 

A  Patent  Omphalomesenteric  Duct  .  — -Kirmisson  f  says  that 
persistence  of  Meckel's  diverticulum  with  an  opening  at  the  umbilicus  is  a  rarity. 
His  patient  was  five  and  one-half  months  old.  The  father  was  not  a  strong  man. 
When  the  cord  came  away  on  the  third  day  the  mother  noticed  a  whitish  swelling, 
which,  eight  days  later,  became  reddish  in  color.  The  swelling  was  the  size  of  a 
strawberry.  Its  mucosa  was  smooth,  and  on  its  surface  were  two  small,  teat-like 
projections,  and  in  its  upper  portion  a  small  orifice  into  which  a  probe  could  be 
carried  3.5  to  -i  cm.  The  mucosa  of  the  nodule  merged  directly  into  the  skin  sur- 
rounding the  umbilicus.  When  the  child  cried  or  moved,  the  tumor  became  larger 
and  larger.     Feces  were  not  detected. 

The  tract  was  dissected  out  and  removed.  It  communicated  with  the  small 
bowel.  The  fistula  was  about  5  cm.  long  and  tapered  off;  its  larger  end  was  at  the 
bowel,  the  smaller,  at  the  umbilicus.     The  child  made  a  good  recovery. 

Microscopic  Examination. — The  mucosa  at  the  umbilicus  resembled  that  of  the 
intestine.  Its  surface  was  covered  with  cylindric  epithelium  and  the  glands  were 
tubular. 

A  Patent  Omphalomesenteric  Duct.  —  Kortet  quoted  Deschin 
as  saying  that  1.8  per  cent,  of  autopsies  in  children  have  shown  remains  of  the 
omphalomesenteric  duct.  He  then  reports  the  case  of  a  boy,  fifteen  months  old, 
who  had  at  the  umbilicus  a  tumor  resembling  a  penis.  When  the  child  cried,  this 
became  larger  than  a  finger.  Its  reduction  was  difficult.  Usually  the  nodule  was 
the  size  of  the  tip  of  a  finger. 

The  child  suffered  with  intestinal  catarrh.  Attributing  this  to  the  open  umbilicus, 
Korte  inserted  an  iodoform  drain  into  the  fistula.  Later  he  resected  it  down 
to  the  bowel.     The  child  made  a  good  recovery. 

Patent  Omphalomesenteric  Duct.  —  Lannelongue  and  Fre- 
mont! refer  to  the  cases  of  fistulse  observed  by  Sandifort,  Schulze,  Tiedemann, 
Ludwig,  and  Tilling,  all  of  which  were  analyzed  by  Cazin. 

They  also  say  that  Bruce  reported  several  instances  in  which  a  small  hernia  of 

*  Kern:    Leber  das  offene  Meckel'sche  Divertikel.     Beitrage  z.  klin.  Chir.,  1S97,  xix,  353. 

t  Kirmisson,  E.:  Persistence  du  diverticule  de  Meckel  ouvert  a  rombilic  avec  prolapsus 
de  la  rnuqueuse  intestinale.    Revue  d'orthopedie,  1901,  xii,  321. 

{  Korte:  Ein  Fall  von  Extirpation  des  persistirenden  Ductus  omphalo-mesentericus. 
Deutsche  med.  Wochenschr.,  1898,  xxiv,  103. 

§  Lannelongue  et  Fremont :  De  quelques  varietes  de  tumeurs  congenitales  de  l'ombilic  et 
plus  specialement  des  tumeurs  adeno'ides  diverticulaires.  Arch.  gen.  de  med.,  1884,  7.  ser.,  xiii, 
36. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  201 

the  umbilicus  was  included  in  the  cord,  and  when  the  cord  dropped  off,  a  small 
orifice  was  left  from  which  feces  and  gas  escaped;  later,  granulation  developed  at 
the  umbilicus,  and  after  a  variable  time  these  openings  closed.  After  considering 
all  the  facts  Duplay  (they  say)  came  to  the  conclusion  that  these  were  hernial 
diverticula. 

Intestinal  Obstruction  Due  to  a  Patent  Omphalo- 
mesenteric Duct.*  —  The  patient  was  a  boy,  ten  years  of  age,  who  was 
said  to  have  had  an  open  umbilicus.  The  physician  who  saw  the  boy  first  when  he 
was  three  years  old  said  it  was  nearly  closed  at  that  time.  Nevertheless,  it  would 
become  prominent,  finally  flatten,  and  discharge  a  few  drops  of  yellowish  fluid 
(odor  not  given).  The  child  had  good  health,  but  frequently  complained  of 
abdominal  pain. 

After  eating  three  apples  he  was  suddenly  seized  with  abdominal  pain,  signs  of 
obstruction  developed,  and  an  operation  was  performed  fourteen  days  later. 

Operation. — When  the  abdomen  was  opened,  a  cord  was  found  passing  from  the 
umbilicus  back  into  the  abdominal  cavity.  It  resembled  intestine,  and  was  the 
size  of  a  finger.  Near  the  umbilicus  it  looked  fibrous,  but  in  the  deeper  portion 
resembled  bowel.  It  had  encircled  a  loop  of  distended  bowel  and  completely 
occluded  it.  Peritonitis  followed,  and  the  patient  died.  The  cord  was  found  -to 
be  the  omphalomesenteric  duct,  which  was  adherent  to  the  umbilicus. 

Case  of  Perforate  Umbilicus. f  —  The  patient  was  a  male  child. 
Projecting  from  the  umbilicus  was  a  tumor  the  size  of  a  hazel-nut.  It  was  bright 
red  in  color,  and  was  perforated  at  its  apex  by  an  orifice  from  which  there  was  a 
continuous  mucous  discharge.  This  opening  led  into  a  long  canal.  There  was  no 
escape  of  urine.  The  fluid  looked  like  and  smelled  like  fecal  contents.  The  mucous 
membrane  was  dissected  away  and  the  wound  closed. 

Marshall  said  that,  although  the  outer  opening  could  be  closed,  there  would 
always  be  a  risk  of  some  of  the  contents  of  the  intestine  passing  into  the  canal  and 
setting  up  irritation  and  suppuration  in  the  region  of  the  umbilicus. 

A  Patent  Omphalomesenteric  Duct.J  —  The  boy  was  born 
with  an  umbilical  hernia.  On  the  fourth  day,  when  the  cord  came  away,  a  red, 
sausage-like  tumor  was  seen,  from  which  feces  and  air  escaped  in  small  quantities. 
The  boy  also  passed  stools  by  the  rectum.  He  cried  and  lost  weight.  The  tumor 
was  covered  with  mucosa,  was  the  thickness  of  a  thumb,  and  projected,  somewhat 
like  a  twisted  horn,  3  cm.  from  the  distended  umbilicus  (Fig.  119).  A  sound  could 
be  introduced  into  it  for  6  to  7  cm.  and  passed  obliquely  upward. 

When  the  child  was  five  weeks  old,  the  abdomen  was  opened  and  the  diverticu- 
lum removed.  The  child  made  a  good  recovery.  Morian  gives  a  table  of  the  cases 
of  patent  omphalomesenteric  duct. 

A  Patent  Omphalomesenteric  Duct.  —  Nicaise §  reports  an 
observation  made  by  Patry.     After  ligation  of  the  cord  the  child  cried,  was  greatly 

*  Leisrink  und  Alsberg:  Einklemmung  seit  14  Tagen,  Laparotomie.  Einschniirung  durch 
einen  off  en  gebliebenen  Ductus  omphalo-mesaraicus;  Resection  des  eingeschniirten  Darmstuckes 
mit  dem  schnlirenden  Strang  ;  Darmnaht.  Tod  nach  6  Stunden.  Langenbeck's  Arch.  f.  klin.  Chir., 
1882,  xxviii,  768. 

t  Marshall:   Med.  Times  and  Gaz.,  1868,  ii,  640. 

t  Morian:  Ueber  das  offene  Meckel'sche  Divertikel.  Langenbeck's  Arch.  f.  klin.  Chir., 
1899,  lviii,  306. 

§  Nicaise:  Ombilic.  Dictionnaire  encyclopedique  des  sciences  medicales,  Paris,  1881,  2.  ser., 
xv, 159. 


202  THE    UMBILICUS   AND    ITS    DISEASES. 

agitated,  vomited,  and  suffered  from  constipation  and  abdominal  distention. 
These  symptoms  persisted  for  four  or  five  days  and  did  not  cease  until  the  ligature 
of  the  cord  came  away,  leaving  a  large  aperture  through  which  an  abundance  of 
greenish  liquid  escaped.  The  child  seemed  to  be  very  much  relieved.  Patry  saw 
the  infant  for  the  first  time  at  the  eighth  month.  He  was  then  much  emaciated. 
The  umbilical  opening  easily  admitted  a  probe.  It  was  surrounded  by  a  collar 
of  mucosa  the  margins  of  which  were  raised,  round,  and  reddish  in  color.  From 
the  opening  there  escaped  a  quantity  of  fecal  material  almost  equal  to  that  passed 
by  the  rectum.  After  feeling  assured  that  the  fecal  material  could  all  escape  by 
the  intestine,  Patry  closed  the  umbilical  orifice.  He  was  able  to  obtain  healing  of 
the  fistula  by  cauterization  and  compression  after  a  term  of  two  months. 

A  Patent  Omphalomesenteric  Duct.*  — ■  The  patient  was  a 
child  thirteen  days  old.  At  birth  an  unusually  thick  cord  was  noted.  When  it 
came  away  on  the  ninth  day  a  red,  moist  surface  was  left  behind.     This  rolled  out 


,J8fefc~ 


Fig.  119. — A  Patent  Omphalomesenteric  Duct.     (After  Morian.) 
The  boy  was  born  with  an  umbilical  hernia.     On  the  fourth  day,  when  the  cord  came  away,  a  red,  sausage-like 
tumor  was  seen.      It  projected  3  cm.  from  the  umbilicus,  and  was  covered  with  mucosa.      It  was  a  patent  omphalo- 
mesenteric duct,  with  some  prolapsus  of  its  mucosa. 

during  the  next  two  days.  Projecting  from  the  umbilicus,  which  was  prominent, 
was  a  red  growth  1  cm.  long,  and  covered  with  mucosa.  At  the  tip  of  the  projec- 
tion was  a  small  opening  the  size  of  a  pin-head,  into  which  a  probe  could  be  intro- 
duced for  8  cm.     A  mucoserous  fluid  escaped,  but  no  feces. 

The  condition  was  diagnosed  as  a  persistent  omphalomesenteric  duct  with  slight 
prolapsus  of  the  everted  intestinal  wall.     It  was  not  thought  to  open  into  the  bowel. 

Operation. — The  abdomen  was  opened  and  the  duct  was  found  attached  to  the 
convex  surface  of  the  small  bowel.  It  was  severed,  and,  with  the  umbilicus, 
removed  intact.     The  child  made  a  good  recovery. 

A  Patent  Omphalomesenteric  Duct.  —  Park's  f  patient  (Case 
2)  was  a  college  athlete  who  gave  a  history  of  always  having  had  some  discharge 
from  the  navel.     A  probe  could  be  passed  downward  through  a  small  opening  for 

*  Xeurath,  Rudolf:  Zur  Casuistik  des  persist  irenden  Ductus  omphalomesaraicus.  Wien. 
klin.  Wochenschr.,  1896,  ix,  1158. 

+  Park,  Roswell:  Clinical  Lecture  on  Congenital  Fistula?  and  Sinuses  at  the  Umbilicus. 
Med.  Fortnightly,  1896,  ix,  9. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  203 

a  distance  of  three  inches.  A  median  abdominal  incision  was  made,  and  the  opera- 
tor found  a  tubular  communication  with  a  loop  of  small  bowel.  The  fistula  was 
exsected  and  the  opening  in  the  bowel  closed.     The  patient  made  a  good  recovery. 

A  Patent  Omphalomesenteric  Duct.  —  In  Pernice's  Case 
142*  it  was  noted  at  birth  that  there  was  an  abnormal  thickening  of  the  umbilicus. 
The  cord  came  away  on  the  ninth  day.  The  umbilicus  did  not  contract  down  and 
close  as  usual,  but  a  greenish,  thick  discharge  from  it  was  noted;  this  gradually 
became  yellow  and  then  whitish  and  turbid.  "When  seen  at  seven  months  of  age, 
the  boy  had  at  the  umbilicus  a  growth  suggesting  " proud  flesh,"  which  was  open 
in  its  center.  The  umbilicus  swelled  out  markedly  whenever  the  child  cried.  The 
skin  in  the  vicinity  was  reddened  and  excoriated,  and  the  skin  papillae  were  some- 
what enlarged.  In  the  middle  of  the  umbilicus  was  a  broad-based,  reddish,  mucus- 
like excrescence,  and  in  the  vicinity  a  funnel-like  depression  which  also  had  a  red- 
dish wall.  A  probe  could  be  passed  down  this  funnel  for  6  cm.  toward  the  pelvis. 
The  canal  was  broad  and  easily  admitted  a  No.  12  bougie.  When  the  child  cried, 
the  funnel  filled  with  a  secretion  resembling  mucus,  which  was  turbid,  alkaline  in 
reaction,  and  contained  particles  of  fecal  matter. 

The  inner  surface  of  the  canal  was  lined  with  cylindric  cells.  The  canal  was 
curetted  with  a  sharp  spoon  several  times,  and  after  five  weeks  it  remained 
closed. 

A  Patent  Omphalomesenteric  Duct.f  —  The  patient  was  a 
male  child,  three  years  old.  His  parents  were  in  good  health.  On  the  fifth  day 
after  birth  the  nurse  made  traction  on  the  cord,  as  it  had  not  come  away.  "In- 
flammation" followed,  and  a  small  opening  developed.  Sometimes  this  opening 
would  close  for  three  weeks  or  more,  but  never  for  a  much  longer  period. 

On  examination  the  mother  was  surprised  to  see  a  worm,  half  an  inch  long, 
crawling  along  the  child's  abdomen.  The  child,  who  had  been  ill,  rapidly  recovered. 
Several  weeks  later  two  worms  similar  in  character  were  extracted  from  the 
umbilical  fistula. 

Between  intervals  of  abdominal  pain  the  child  enjoyed  good  health,  except  for 
occasional  pain  due  to  the  worms.  At  the  umbilicus  was  a  slight  projection  the 
size  of  a  hazelnut,  with  an  opening  in  the  center  which  discharged  contents  resem- 
bling feces. 

On  several  occasions  a  physician  was  called  to  see  the  child  when  in  great  pain 
and  removed  lumbricoid  worms  from  the  fistula. 

A  Patent  Omphalomesenteric  Duct.*  —  The  umbilical  cord 
was  unusually  thick,  for  an  inch  and  a  half  from  the  abdomen,  being  more  than 
double  the  caliber  of  the  rest  of  the  cord.  The  ligature  was  applied  distally  to  this 
thickening,  the  resultant  stump  being  unusually  tense  and  hard.  On  the  ninth 
day  the  covering  at  the  top  sloughed,  revealing  a  red,  granular  projection.  At 
the  end  of  a  month  the  outer  covering  had  disappeared,  and  a  firm,  smooth,  red 
tumor  remained.  This  was  one  and  a  half  inches  long,  pyriform  in  shape,  and 
attached  to  the  umbilicus  by  a  short  but  thick  pedicle.     Its  outer  extremity  pre- 

*  Pemice,  L.:   Die  Nabelgeschwiilste,  Halle,  1892. 

f  Poussin:  Observation  sur  l'expulsion  de  l'abdomen,  par  une  ouverture  a  l'ombilic,  de 
plusieurs  vers  ascarides-lombricoides.     Jour,  de  med.,  1817,  xl,  81. 

t  Pratt,  J.  W. :  A  Remarkable  Case  of  Umbilical  Tumor.  The  Lancet,  London,  18SL  ii, 
1142. 


204  THE    UMBILICUS    AND    ITS    DISEASES. 

seated  a  central  orifice  from  which  a  watery  fluid  exuded  more  or  less  constantly. 
There  was  no  evidence  of  hernia.  The  growth  was  not  painful,  but  bled  when 
handled,  unless  treated  gently  with  oiled  fingers.  It  became  vascular  when  the 
child  cried.  Toward  the  end  of  the  third  week  after  birth  fecal  matter  commenced 
to  escape.  This  phenomenon  was  noted  every  three  or  four  days  during  the 
following  month.     The  child's  general  health  was  good. 

"When  the  child  was  seven  weeks  old,  a  strong  silk  ligature  was  tied  around  the 
pedicle  of  the  growth.  Three  days  later,  on  removal  of  the.  dressing,  the  growth 
was  found  detached.  The  raw  area  was  dressed  with  zinc  ointment  and  a  pad 
applied.  In  a  few  days  nothing  but  an  induration  was  noted  around  the  umbilicus. 
The  child  was  well  a  few  days  later.     There  was  no  return  of  the  fistula. 

An  Omphalomesenteric  Duct  so  Nearly  Patent  that 
Moderate  Pressure  was  Sufficient  to  Force  Intestinal 
Contents  Through  the  Umbilicus.  —  In  a  male  infant  at  term 
Prestat*  demonstrated  an  intact  umbilical  cicatrix.  On  opening  the  abdomen 
he  found  a  cord  the  size  of  a  goose-quill,  2^  inches  long,  and  communicating  with 
the  small  intestine.  This  opening  was  oblique  and  passed  from  the  convex  side  of 
the  bowel.  When  pressure  was  exerted  on  the  small  bowel,  fecal  matter  passed 
along  the  fistula  and  caused  a  pouting  out  of  the  umbilical  cicatrix.  This  readily 
yielded,  allowing  feces  to  escape,  thus  demonstrating  conclusively  that  the  omphalo- 
mesenteric duct  was  practically  patent  along  its  entire  course  and  merely  sealed 
over  at  the  umbilicus. 

A  Series  of  Patent  Omphalomesenteric  Ducts. — 
Quaet-Faslem  f  gives  a  very  good  resume  of  the  literature  on  the  origin  of  the 
omphalomesenteric  duct,  and  then  reports  five  cases  of  persistent  patency.  The 
first  case  had  been  already  recorded  by  Hansen  in  his  inaugural  dissertation  (Kiel, 
1885). 

In  Case  2  of  his  series  a  boy,  nine  days  old,  was  admitted  to  the  hospital,  on 
January  4,  1888,  because  feces  were  escaping  at  the  umbilicus.  At  the  navel  was 
a  long,  pear-shaped  tumor,  8  to  10  cm.  long,  with  an  opening  in  the  center.  A 
sound  could  be  passed  through  it  into  the  abdomen. 

The  tumor  was  cut  off  with  scissors  and  the  opening  closed  with  catgut.  The  boy 
made  a  satisfactory  recovery.     The  fistula  was  a  patent  omphalomesenteric  duct. 

Case  3  (1892).  A  ten-months-old  male  child  presented  a  prominent  umbilicus 
with  a  small  opening  from  which  mucus  escaped.  The  tumor  was  removed  and 
the  wound  successfully  closed. 

Case  4  (1885)  was  that  of  a  boy  two  days  old  in  whom  a  blackish-green  cord  still 
remained.  There  was  also  a  conic,  red  umbilical  tumor,  showing  at  its  summit 
a  small  opening  from  which  mucus  escaped.  When  the  child  coughed  or  moved, 
small  fecal  masses  came  away.  The  tumor  was  removed  and  the  lumen  closed, 
with  good  results. 

Case  5  (1895).  A  girl,  five  years  old,  was  admitted  because  the  umbilicus  had 
never  healed  and  secreted  fluid.  Around  the  umbilical  opening  was  a  reddening, 
and  at  the  umbilicus  was  a  hernia  the  size  of  a  nut,  from  the  center  of  which  a 

*  Prestat  (quoted  by  Ledderhose) :  Chirurgische  Erkrankungen  des  Nabels.  Deutsche 
Chirurgie,  1890,  Lief.  45  b. 

t  Quaet-Faslem :  Das  Offenbleiben  des  Ductus  omphalo-mesentericus.  Inaug.  Diss.,  Kiel, 
1899. 


A    PATENT    OMPHALOMESENTERIC    DUCT. 


205 


yellowish  secretion  escaped.  The  child  was  very  thin  and  pale.  A  diagnosis  of 
persistence  of  the  omphalomesenteric  duct  was  made. 

Operation. — The  tract  was  dissected  out,  cut  off,  and  the  hole  in  the  bowel 
closed.  The  results  were  satisfactory.  It  is  unusual  to  find  so  many  cases  reported 
from  the  same  clinic  (Petersen's).  The  cases,  though  perfectly  clear,  are  frag- 
mentary. 

A   Patent   Omphalomesenteric   Duct   with  the   Central 
Portion     Partially     Closed,     Preventing      the      Further 
Escape   of  Feces.*  —  The  patient  (L.  P.),  eleven  months  old,  had  a  small, 
smooth  projection  half  an  inch  long  and  one- 
eighth  of  an  inch  in  diameter  at  the  umbilicus. 
This  was  red,  cylindric,  and  covered  with  mucosa. 
There  was  no  aperture  leading  to  the  abdominal 
cavity.    The  mother  stated  that  for  some  months 
after  the  birth  of  the  child  there  had  been  a  very 
foul  discharge  from  the  navel.     This  was  fecal  in 
character.     Xow  there  was  no  escape  of  feces, 
and  only  occasionally  moisture. 

The  projection  was  ligated  and  nipped  off, 
and  the  child  left  the  hospital  three  days  later  in 
good  condition. 

On  microscopic  examination  the  umbilical 
polyp  was  found  covered  with  intestinal  mucosa. 
In  some  places  the  covering  had  been  rubbed  off. 
Railton  comments  on  the  closure  of  part  of  the 
fistulous  tract,  thereby  shutting  off  the  escape  of 
feces.  The  closure  was  probably  caused  by  new 
connective-tissue  formation. 

A  Patent  Omphalomesenteric 
Duct.  —  Roth  (p.  383), f  in  the  description 
of  Case  3,  refers,  to  a  boy,  nearly  a  month  old, 
who  exhibited  an  unusual  outgrowth  at  the  um- 
bilicus after  the  cord  came  away.  The  tumor 
was  cylindric,  red  in  color,  and  about  the  size  of 
the  last  phalanx  of  a  small  finger.  The  cord  was 
unusually  large  and  came  away  on  the  eighth  clay. 

When  the  child  was  brought  to  the  hospital, 
this  projection  was  2  cm.  long,  and  a  sound  could 

be  introduced  4  cm.  downward.  The  surface  of  the  tumor  was  velvety.  From  the 
fistula  bile,  yellow  grumous  masses,  and  vegetable  matter  escaped,  showing  conclu- 
sively that  it  was  a  fecal  fistula.     The  child  died  suddenly  when  six  months  old. 

From  a  loop  of  small  bowel  the  diverticulum  extended  to  the  umbilicus.  From 
the  mesentery  a  delicate  fold  passed  over  the  intestine  and  was  adherent  to  the 
umbilical  ring  (Fig.  120,  b).     In  this  fold  several  vessels  were  seen.     The  diver- 


Fig.  120. — A  Patext  Omphalomesenteric 
Duct.  (After  Roth.) 
A  longitudinal  section  through  the  pat- 
ent duct  and  the  surrounding  tissues,  a  is 
the  valve-like  flap  of  mucosa  where  the  om- 
phalomesenteric duct  opened  into  the  small 
bowel,  b  indicates  the  point  of  attachment 
of  the  duct  to  the  peritoneum  of  the  anterior 
abdominal  wall.  Just  beneath  it  is  the  om- 
phalomesenteric artery,  c  is  the  edge  of  the 
peritoneal  fold  just  above  the  diverticulum. 
It  will  be  noted  that  the  outer  portion  of  the 
duct  really  formed  a  penile  projection  ex- 
tending downward  from  the  surface  of  the 
abdomen. 


*  Railton,  T.  C:  Prolapse  of  Meckel's  Diverticulum  (Omphalo-mesenteric  Duct).  Brit. 
Med.  Jour.,  1893,  i,  795. 

t  Roth,  M.:  ITeber  Missbildungen  im  Bereich  des  Ductus  omphalo-mesentericus.  Virchows 
Arch  ,  1881,  Lxxxvi,  371. 


206 


THE    UMBILICUS    AXD    ITS    DISEASES. 


ticulum  was  58  cm.  above  the  ileocecal  valve.  It  gradually  became  smaller  as  it 
passed  from  the  small  bowel  to  the  umbilicus.  There  was  a  definite  valve  (Fig. 
120,  a)  where  the  diverticulum  passed  from  the  intestine  outward. 

A  Patent  Omphalomesenteric  Duct.*  —  In  May,  1903,  a 
strong  five-months-old  girl  was  brought  to  the  clinic  with  a  history  that,  soon  after 
the  dropping  off  of  the  cord  on  the  sixth  da}r,  there  had  been  observed  a  small  red 
tumor  at  the  umbilicus.  An  odor  had  been  detected  only  a  little  while  before  ad- 
mission. The  tumor  had  an  opening  at  its  tip,  and  from  this  now  and  then  drops 
of  clear  mucus  were  discharged. 
It  had  not  increased  in  size,  but 
wheu  the  child  cried  or  when 
pressure  was  exercised,  it  be- 
came a  little  more  prominent . 

The  umbilical  nodule  was 
about  the  size  of  a  pea.  It  was 
reddish  and  velvet  -like,  with  a 
fistulous  opening  in  the  middle 
through  which  a  sound  could  be 
easily  passed  for  2  cm.  into  the 
abdominal  cavity  (Fig.  121). 
The  tumor  was  somewhat  pe- 
dunculated. The  mother  said 
that  there  had  never  been  any 
discharge  of  fecal  matter  from 
the  fistula,  and  that  the  child's 


Fig.  121. — A  Patent  Omphalomesenteric 
Duct.  (After  Salzer.) 
/'  is  the  tumor:  .V,  the  attachment  to 
the  abdominal  wall;  D,  the  opening  into  the 
bowel.  For  the  low-power  picture  see  Fig. 
122.     For  the  high-power  see  Fig.  123. 


Fig.  122. — Paht  of  a  Patent  Omphalomesenteric  Duct.  (After 
Salzer.) 
Fig.  122  shows  a  longitudinal  section  of  Fig.  121,  on  one  side  of 
the  fistulous  tract.  The  entire  outer  surface  of  the  tumor  is  covered 
over  with  typical  intestinal  mucosa.  MD  indicates  a  point  where 
the  glands  show  some  branching.  E  shows  the  squamous  epithe- 
lium. The  line  of  junction  between  the  skin  and  the  mucosa  is 
sharply  defined.     For  the  high-power  picture  see  Fig.  123. 


stools  had  always  been  regular.  From  the  history  there  was  no  doubt  that  the 
condition  was  due  to  persistence  of  the  omphalomesenteric  duct.  The  only  ques- 
tion was  as  to  whether  the  fistula  was  complete  or  partial. 

Operation,  June  26,  1903. — An  elliptic  incision  was  made,  encircling  the 
umbilicus,  and  a  cord  was  found  passing  from  the  navel  to  the  convex  side  of  the 
small  bowel.     This  cord  was  2  cm.  long  and  0.5  cm.  thick.     It  was  covered  with 

*  Sulzr;r,  H.:  Ueber  das  offene  MeckePsche  Divertikel.  Wien.  klin.  Wochenschr.,  1904,  xvii, 
614. 


A    PATENT    OMPHALOMESENTERIC    DUCT. 


207 


peritoneum  on  all  sides.  Blood-vessels  passed  from  the  mesentery  over  the  bowel 
to  this  cord. 

The  diverticulum  was  cut  off  at  the  bowel;  the  bowel  was  closed,  and  the  child 
made  a  perfect  recovery. 

The  tumor  was  hardened  in  Muller  formalin  solution  and  then  in  alcohol  of 
different  strengths  and  embedded  in  paraffin.  Serial  sections  were  cut  in  such  a 
manner  that  they  ran  parallel  with  the  course  of  the  diverticulum  throughout. 
In  some  sections  it  was  possible  to  see  that  the  lumen  of  the  intestine  was  open  and 


A.D. 


v-ay-/-- 


Fig.  123. — Intestinal  Mucosa  Covering  the  Cutaneous  or  Umbilical  End  of  a  Patent  Omphalomesenteric 

Duct.     (After  Salzer.) 
Fig.  123  shows  a  small  portion  of  Fig.  121.     At  M.D.  is  a  large  gland.     On  being  followed  downward,  its  branches 
are   clearly  seen.     D.D.  indicates  goblet-cells.     The   surface   of  the  mucosa  shows  some  degeneration,  evidently  on 
account  of  coming  in  contact  with  the  clothing. 


communicated  with  the  umbilical  fistula.  Some  of  the  sections  were  stained  with 
hemalum-eosin  and  some  by  the  van  Gieson  method.  The  peritoneal  covering 
of  the  diverticulum  was  seen  to  be  directly  continuous  with  that  of  the  intestine  as 
far  as  the  abdominal  wall. 

The  nerve  elements  of  Meissner's  and  of  Auerbach's  plexus  were  found  in  their 
normal  positions  in  all  portions  of  the  diverticulum.  The  mucosa  of  the  diverticu- 
lum presented  points  of  much  interest.  In  its  free  abdominal  portion,  as  well  as 
in  the  region  of  the  abdominal  wall,  it  was  identical  with  the  normal  mucosa  of  the 
small  intestine.     But  where  it  lay  free  on  the  surface  of  the  prolapsus  on  the 


208  THE    UMBILICUS    AND    ITS    DISEASES. 

abdomen,  the  character  of  the  glands  was  markedly  changed.  The  gland  tubules 
were  smaller  than  Lieberkiihn's  crypts.  They  often  showed  bifurcation  or 
numerous  branches  and  were  tortuous  (Fig.  123).  The  gland-cells  were  clear,  finely 
granular,  polygonal  in  shape,  and  showed  a  nucleus  resting  on  the  base.  They  took 
the  eosin  weakly,  and  the  glands  themselves  did  not  pass  as  deeply  as  those  of 
Lieberkiihn. 

Professor  v.  Ebner  and  Professor  Schaff er,  who  examined  the  specimens,  said  that 
all  these  glands  bore  some  resemblance  to  those  of  the  cardiac  end  of  the  stomach. 
At  the  point  where  the  mucosa  passed  into  the  skin,  the  Lieberkiihn  glands  with 
numerous  goblet-cells  were  again  visible  (Fig.  122).  A  portion  of  the  duct  re- 
sembled, as  Professor  Ebner  said,  the  mucosa  of  the  large  bowel. 

Salzer  says  that,  to  epitomize  the  findings,  we  have  a  case  of  a  patent  omphalo- 
mesenteric duct. 

A  Patent  Omphalomesenteric  Duct.*  —  J.  W.,  about  ten 
months  old,  was  brought  to  the  clinic  on  February  27,  1896.  On  the  fifth  day  after 
the  cord  had  come  away  a  granulation  was  noted  at  the  umbilicus.  This  had  an 
opening  the  size  of  a  darning-needle.  It  was  surrounded  by  reddish  walls,  and  by 
making  pressure  the  midwife  could  bring  away  sausage-like  masses  of  fecal  matter 
from  the  umbilicus.  The  reddish  walls  became  higher  and  thicker,  and  as  the  fecal 
discharge  did  not  cease,  the  child  was  brought  to  Dr.  Noder,  July  31,  1895. 
Noder  was  able  to  introduce  a  sound  fully  10  cm.  into  the  abdominal  cavity,  and 
at  once  greenish,  soft  fecal  matter  and  greenish-colored  fluid  escaped.  By  gradu- 
ally pressing  inward,  as  one  would  do  with  a  prolapsed  anus,  he  could  diminish  the 
size  of  the  tumor.  As  a  result  of  four  applications  of  the  cautery,  the  fistula 
became  so  constricted  that  only  mucus  and  watery  fluid  escaped  from  it. 

As  the  child  was  not  in  very  good  physical  condition,  he  was  brought  to  the 
hospital.  Projecting  from  the  umbilicus  was  a  sausage-like  body,  4.5  cm.  long, 
which  spread  out  over  the  abdomen  (Fig.  124).  From  its  form  and  also  its  color 
it  was  easily  seen  that  it  was  divided  into  two  portions.  The  first  was  in  intimate 
connection  with  the  abdominal  wall  (Fig.  124,  a).  It  was  2.5  cm.  long,  about 
the  thickness  and  roundness  of  a  man's  finger,  and  covered  over  with  a  prolongation 
of  the  abdominal  skin.  Sitting  on  this  like  a  cap  was  a  second  portion.  It  was 
red,  strawberry-shaped  (Fig.  124,  b),  and  covered  over  with  a  shiny  red  mucosa 
which  secreted  an  abundant  quantity  of  mucus.  Where  the  first  mass  joined  the 
second,  there  was  a  rather  deep  depression.  No  opening  could  be  made  out.  There 
was,  however,  at  the  top  of  the  red  tumor  a  slight  depression  (Fig.  124,  c),  but  a 
probe  could  not  be  introduced. 

On  pressure  the  two  portions  of  the  tumor  were  found  to  differ  in  consistence; 
the  first  was  hard  and  cord-like;  the  second  was  softer  and  could  be  pressed  together 
somewhat,  but,  nevertheless,  was  firm  and  uniform.  On  pressure  both  developed 
some  gurgling  and  could  be  reduced  in  size.  When  the  child  took  a  long  breath 
the  entire  mass  was  pushed  outward  and  then  receded  again. 

The  abdominal  walls  were  excoriated.  Digestion  and  defecation  were  normal. 
The  fluid  was  alkaline  in  reaction  and  contained  mucin.  There  was  no  evidence 
whatever  of  urine  at  the  umbilicus.     The  case  was  diagnosed  as  one  of  a  Meckel's 

*  Sauer,  Felix:  Ein  Fall  von  Prolaps  eines  offenen  Meckel'schen  Diver tikels  am  Nabel. 
Deutsche  Zeitschr.  f.  Chir.,  1896-97,  xliv,  316. 


A    PATENT    OMPHALOMESENTERIC    DUCT. 


209 


diverticulum  reaching  to  the  umbilicus  and  originally  communicating  with   the 
surface. 

Operation. — When  the  peritoneum  was  opened,  it  was  found  that  the  tract  had 
communicated  with  a  loop  of  the  small  bowel.     The  diverticulum  was  cut  off,  the 
end  turned  in,,  and  the  growth  removed.     The  diverticulum  was  3  cm.  in  length. 
The   child   developed  peritonitis 
and  died  on  the  third  day. 

Sauer  then  goes  on  to  give  a 
careful  description  of  the  micro- 
scopic findings.  He  sums  up  as 
follows:  At  a  point  53  cm.  d 
above  the  ileocecal  valve  is  the 
Meckel  diverticulum  which  ex- 
tends through  the  umbilical  ring.  g 
After  the  dropping  off  of  the  um- 


Fig.  124. — An  Umbilical  Polyp  and  a  Fibrous 
Nodule  at  the  Umbilicus.     There  was 
Originally   a    Patent    Omphalomesen- 
teric Duct.     (After  Sauer.) 
a  is  a  portion  of  the  prolapsus  covered  with 
skin;  6,  the  outer  end  of  the  omphalomesenteric 
duct,  covered  over  with  mucosa  and  formerly 
opening  into  the  bowel;  c  indicates  the  depres- 
sion whence  the  fecal  matter  had  at  one  time 
escaped.     The  opening  was  closed  by  means  of 
the  thermocautery.    For  the  microscopic  picture 
see  Fig.  125. 


Fig.  125. — Longitudinal  Section  through  the  Entire  Cen- 
ter of  a  Partially  Closed  Omphalomesenteric  Duct. 
(After  Sauer.) 

For  the  general  appearance  of  the  umbilical  tumor  see  Fig. 
124. 

a,  a  portion  of  the  tumor  lying  on  the  abdominal  wall.  The 
tumor,  b,  is  covered  over  with  skin  and  consists  of  tissue  of  the 
abdominal  wall;  c,  the  tumor  covered  over  with  mucosa;  d,  the 
prominent  hypertrophied  mucosa  of  the  diverticulum;  e,  the  de- 
pression where  communication  with  the  diverticulum  opening  into 
the  bowel  had  formerly  taken  place;  /,  line  of  junction  between 
the  skin  and  the  mucosa;  g,  blood-vessels;  h,  the  portion  of 
Meckel's  diverticulum  communicating  with  the  bowel;  i,  a  por- 
tion of  Meckel's  diverticulum  has  been  nipped  off  and  scar  tissue 
has  formed  as  a  result  of  cauterization;  k,  marked  thickening  of 
the  mucosa;   I,  scar  tissue  where  the  lumen  formerly  existed. 


bilical  cord  the  diverticulum  becomes  adherent  to  the  abdominal  ring.  Through 
mechanical  pressure  feces  escape,  then  prolapsus  of  the  diverticulum  takes 
place. 

By  means  of  the  thermocautery  the  outer  portion  of  the  opening  was  closed. 
Fortunately,  there  was  no  prolapse  of  the  intestine.     The  opening  was  still  closed 
at  the  end  of  about  three  months.     The  solid  portion  of  the  tumor  is  shown  in 
15 


210  THE    UMBILICUS    AND    ITS    DISEASES. 

Figs.  124  and  125,  and  consists  of  fibrous  tissue.  The  reddish  tumor  is  covered 
with  typical  intestinal  mucosa. 

A  Patent  Omphalomesenteric  Duct.  —  Schroeder  *  says  that 
in  the  Prag.  Path.-anat.  Museum  (Protocol  479,  1849)  is  the  record  of  a  child  six 
months  old.  The  embryonic  omphalomesenteric  duct  was  present.  It  passed 
from  the  umbilicus  to  the  ileum  as  a  canal  increasing  in  size  until  it  joined  the  bowel. 

A  Patent  Omphalomesenteric  Duct.  |  —  The  patient  was  a 
strong,  healthy  boy  three  months  old.  He  was  admitted  to  the  hospital  with  a 
fecal  fistula  at  the  umbilicus.  At  birth  the  cord  was  thicker  than  usual.  The 
ligature  came  away  on  the  fifth  day,  and  on  the  following  day  the  nurse  noticed 
flatus  escaping  from  the  umbilicus;  later,  feces  were  discharged  in  large  or  small 
quantities.  A  few  days  after  the  cord  came  away  the  umbilical  growth  protruded 
more  markedly. 

At  the  site  of  the  umbilicus  was  a  protrusion  which  was  the  size  of,  and  had  the 
appearance  of,  a  child's  penis.  This  projection  was  V/^  inches  long  and  had  at  its 
extremity  an  opening  which  looked  very  much  like  a  preputial  orifice.  The  growth 
was  covered  over  with  mucosa  and  bled  easily.  For  three  or  four  inches  around 
the  umbilicus  the  skin  was  raw,  red,  and  eczematous.  A  probe  could  be  introduced 
into  the  projection,  and  feces  escaped.  The  fistulous  tract  was  large  enough  to 
admit  easily  a  pair  of  artery  forceps. 

Operation. — The  abdomen  was  opened;  the  diverticulum  was  cut  off,  and  the 
hole  in  the  bowel  closed.     The  child  made  a  good  recovery. 

A  Patent  Omphalomesenteric  Duct.  J  —  A  boy,  aged  seven, 
was  brought  to  the  hospital  on  account  of  a  lumbricoid  worm  which  was  protruding 
from  the  umbilicus.  MacSwiney  says:  "I  at  once  proceeded  to  deliver  it  in  an 
artistic  way,  and  I  had  to  exercise  some  caution  in  the  operation  lest  it  should  break; 
as  there  was  considerable  tension  on  the  creature,  and  it  was  evident  that  its  body 
was  tightly  compressed  in  a  tract  or  sinus  through  which  it  was  slowly  making  its 
way  out." 

The  father  said  that  since  birth  there  had  been  a  fistula  at  the  umbilicus  and 
that  it  constantly  discharged.  There  was  never,  however,  any  sign  of  blood,  bile, 
or  feces.  The  discharge  was  clear  yellow  matter  with  no  fecal  odor.  MacSwiney, 
and  his  friend,  Dr.  Kelly,  thought  the  case  to  be  one  of  an  unclosed  vitelline  duct. 

A  Patent  Omphalomesenteric  Duct.§  —  A  male  child,  two 
months  old,  was  admitted  June  1,  1896.  The  labor  had  been  normal.  The  old 
midwife  said  that  in  her  long  experience  she  had  never  seen  so  large  an  umbilicus 
in  the  new-born. 

When  the  cord  came  away,  the  mother  had  noticed  at  the  umbilicus  a  reddish 
tumor  from  the  point  of  which  intestinal  contents  were  discharged.  Since  birth 
the  tumor  had  grown  but  very  little.  The  child  was  well  developed  and  healthy. 
At  the  umbilicus  was  a  tumor  the  size  of  a  hazel-nut.     In  form  it  resembled  a  penile 

*  Schroeder,  G.:  Ueber  die  Diverlikel-Bildungen  am  Darmkanale.  Inaug.  Diss.  (Erlangen), 
Augsburg,  1854. 

t  Shepherd,  F.:  Umbilical  Fecal  Fistula  in  an  Infant  Cured  by  Radical  Operation.  Arch. 
of  Pediatrics,  L892,  ix,  55. 

%  MacSwinev,  S.  M.:  Ascaris  Lumbricoides  extracted  from  an  Umbilical  Fistula.  Proc. 
Path.  Soc.  of  Dublin,  1873-75,  vi,  251. 

\  Stierlin,  R. :  Zur  Casuistik  angeborener  Nabelfisteln.  Deutsche  med.  Wochenschr.,  1897, 
xxiii,  188. 


A    PATENT    OMPHALOMESENTERIC    DUCT. 


211 


gland.  It  was  dark  red  in  color,  velvety,  glistening,  and  reminded  one  of  intestinal 
mucosa.  At  the  point  of  the  tumor  was  an  opening  which  admitted  a  sound;  at 
the  base  was  a  ring  of  indurated  tissue,  4.5  mm.  broad,  which  surrounded  the 
tumor  as  a  cuff.  When  the  child  cried,  the  tumor  was  a  little  more  prominent. 
If  pressure  was  made  on  the  abdomen,  there  escaped  a  small  quantity  of 
gas  and  fluid  fecal  matter  from  the  umbilicus.  A  metallic  sound  passed  6  to 
8  cm.  downward;  an  elastic  catheter,  25  cm.  and  farther,  without  any  difficulty. 
Defecation  and  urination  were  normal.  Stierlin  came  to  the  conclusion  that 
he  had  to  deal  with  a  diverticulum. 

The  skin  ring  at  the  umbilicus  was  split  upward  and  downward.  It  was  then 
easy  to  separate  the  tumor  from  the  surrounding  structures.  On  making  traction 
and  continuing  the  dissection  Stierlin  found  that  the  fistula  passed  to  the  convex 
side  of  the  small  bowel.     The  diverticulum  was  6  cm.  long  (Fig.  126). 

While  the  dissection  was  being  made,  it  was  noted  that  an  artery  had  been 
injured.  This  was  isolated,  tied,  and  dropped  back 
into  the  abdomen.  It  was  a  persistent  omphalo- 
mesenteric artery.  The  base  of  the  diverticulum 
was  now  clamped,  and  the  diverticulum  removed. 
The  opening  in  the  bowel  was  closed  with  two  con- 
tinuous silk  sutures.  The  child  made  a  good  re- 
covery. 

Strangulation  of  Intestine  by 
Diverticulum  Ilei.  — Wilks*  reported  a 
case  of  obstruction  caused  by  Meckel's  divertic- 
ulum. The  child  had  previously  undergone  a 
successful  plastic  operation  for  fecal  fistula  at  the 
umbilicus. 

A  Patent  Omphalomesenteric 
D  u  c  t  .  f  — ■  Peter  M.,  three  weeks  old,  had  an 
umbilical  fistula  which  had  been  noted  soon  after 
the  cord  came  away.  A  great  deal  of  fecal  matter 
escaped.  Surrounding  the  opening  was  a  small  fun- 
gous wall.  Caustics  were  applied  to  the  fistulous 
tract,  and  a  bandage  was  put  on,  but  without  suc- 
cess. Several  years  later  the  child  was  brought  back. 
The  fistula  had  become  smaller,  but  fecal  matter  still  escaped 
tried,  this  time  with  success. 

A  Patent  Omphalomesenteric  Duct.  J  —  Frederick  W.,  seen 
by  Wernher,  was  a  twin  child  eleven  weeks  old,  and  well  formed.  The  parents 
said  that  the  child  had  had  intestinal  obstruction.  At  other  times  there  would  be 
abdominal  pain  and  diarrhea.  He  cried  a  good  deal  and  vomited.  On  examina- 
tion the  umbilicus  was  found  to  be  prominent.  Surrounding  the  margin  of  the 
fistula  was  a  fleshy  wall  which  bled  readily  and  was  covered  with  brownish  crusts. 
Wernher  lost  track  of  the  child,  but  it  was  brought  back  three  months  later.     The 


Fig.  126. — A  Patent  Omphalomes- 
enteric Duct.  (After  Stierlin.) 
A  diverticulum,  springing  from 
the  convex  surface  of  a  loop  of  small 
bowel.  It  was  6  cm.  long,  and  ended 
in  a  mushroom-like  extremity.  It  was 
cut  off  at  the  line  indicated  by  a-a 
and  inverted  just  as  one  would  do 
with  an  appendix. 


Caustics  were  again 


*  Wilks,  Samuel:   Trans.  Path.  Soc.  London,  1865,  xvi,  126. 

f  Weiss,  Eduard :  Ueber  diverticulare  Nabelhernien  und  die  aus  ihnen  hervorgehenden  Nabel- 
fisteln.     Inaug.  Diss.,  Giessen,  1868. 
X  Weiss,  Eduard :   Op.  cit. 


212  THE    UMBILICUS    AND    ITS    DISEASES. 

projection  at  the  umbilicus  was  hard,  and  when  the  child  cried,  a  few  drops  of  brown- 
ish fecal  matter  escaped.  Cauterization  was  tried  and  the  amount  of  fecal  discharge 
diminished.     Eight  days  later  the  opening  was  closed  and  the  bowels  were  regular. 

Six  months  later  the  child  was  again  admitted.  A  week  before  admission  it 
had  coughed  a  great  deal,  and  as  a  result  of  the  coughing  a  prominence  was  noticed 
at  the  umbilicus.  The  digestion  had  been  disturbed  for  some  time,  and  there  were 
diarrhea  and  colic.  As  a  result  of  severe  coughing  the  umbilical  scar  broke  and 
yellowish  fecal  matter  and  some  blood  escaped.     The  child  soon  died. 

Autopsy. — A  Meckel's  diverticulum  was  found  extending  from  the  convex  side 
of  the  bowel;  it  had  a  mesentery  of  its  own.  The  mucosa  of  the  diverticulum  of 
the  ileum  was  much  injected.     It  opened  at  the  umbilicus  by  a  small  passage. 


LITERATURE  CONSULTED  ON  PATENT  OMPHALOMESENTERIC  DUCT. 

Alsberg,  A. :  Ueber  einen  Fall  von  Radicaloperation  eines  persistirenden  Ductus  omphalo-meserai- 

cus.     Deutsche  med.  Wochenschr.,  1892,  xviii,  1040. 
Ardouin,  P.:   Persistance  du  diverticule  de  Meckel  ouvert  a  l'ombilic,  fistule  stercorale,  omphal- 

ectomie,  extirpation  du  diverticule,  guerison.  Arch.  prov.  de  Chir.,  1908,  xvii. 
Barth,  A. :  Ueber  die  Inversion  des  offenen  Meckel'schen  Divertikels  und  ihre  Complication  mit 

Darmprolaps.     Deutsche  Zeitschr.  f.  Chir.,  1887,  xxvi,  193. 
Battle,  W.  H.:   Extroversion  of  Meckel's  Diverticulum.     Clin.  Soc.  Trans.,  London,  1893,  xxvi, 

237. 
Billroth:    Chir.  Klinik,  Berlin,  1869,  294. 

Broadbent:  Patent  Vitelline  Duct.     Med.  Times  and  Gaz.,  1866,  ii,  45. 
Broca,  A. :  Persistance  du  diverticule  de  Meckel  ouvert  a  l'ombilic  et  invagine  au  dehors.     Revue 

d'orthopedie,  1895,  vi,  47. 
Bureau,  J.:  Prolapsus  ombilical  du  diverticule  de  Meckel.     These  de  Paris,  1898,  No.  257. 
Brun,  L.  A. :  Sur  une  espece  particuliere  de  tumeur  fistuleuse  stercorale  de  l'ombilic.     These  de 

Paris,  1834,  No.  238. 
Deschin:  Zur  Frage  der  chirurgischen  Behandlung  bei  dem  Vorfall  des  Dotterganges.     Centralbl. 

f.  Chir.,  1895,  xxii,  1154. 
Eves:   A  Case  of  Diverticulum  Ilei  Communicating  with  the  Umbilicus.     The  Lancet,  London, 

1845,  i,  101. 
Fitz,  R.:  Persistent  Omphalomesenteric  Remains,  their  Importance  in  the  Causation  of  Intestinal 

Duplication,  Cyst-formation,  and  Obstruction.     Amer.  Jour.  Med.  Sci.,  1884,  lxxxviii,  30. 
Froelich,  R.:    Fongus  ombilical  du  nouveau-ne,  prolapsus  ombilical  du  diverticule  de  Meckel. 
Etude  de  chir.  infantile,  Paris,  1905,  85.     Du  Fongus  ombilical  du  nouveau-ne,  a  l'occasion 
d'une  operation  de  prolapsus  ombilical  du  diverticule  de  Meckel.     Rev.  mens,  des  mal.  de 
l'enfance,  Paris,  1902,  xx,  517. 
Gevaert,  G.:   Fistule  ombilicale  diverticulaire  chez  un  enfant.     Ann.  de  med.  et  de  chir.,  1892, 

iv,  1. 
Hansen,  J.  A.:    Ein  Beitrag  zur  Persistenz  des  Ductus  omphalo-entericus.     Inaug.  Diss.,  Kiel, 

1885. 
Heaton,  G.:  Fecal  Concretion  discharged  at  the  Umbilicus.     Brit.  Med.  Jour.,  1898,  i,  627. 
Hickman:  Persistent  Vitelline  Duct.     Trans.  Path.  Soc.  London,  1869,  xx,  418. 
Holmes,  T.:  Surgical  Treatment  of  Diseases  of  Children,  London,  1868,  181. 
Jacoby,  M.:  Zur  Casuistik  der  Nabelfisteln.     Berlin,  klin.  Wochenschr.,  1877,  xiv,  202;  Jahrbuch 

fur  Kinderheilkunde  und  phys.  Erzieh.,  1878,  xii,  144. 
Kehr,  II.:    Leber  einen  Fall  von  Radicaloperation  eines  persistirenden  Ductus  omphalomese- 

raicus.     Deutsche  med.  Wochenschr.,  1892,  xviii,  1166. 
King,  T.  W.:  Fajculent  Discharge  at  the  Umbilicus  from  Communication  with  the  Diverticulum 

Ilei.     Guy's  Hospital  Reports,  1843,  i,  2.  series,  467. 
Kern:  Ueber  das  offene  Meckel'sche  Divertikel.     Beitrage  z.  klin.  Chir.,  1897,  xix,  353. 
Kirmisson,  E.:    Persistance  du  diverticule  de  Meckel  ouvert  a  l'ombilic  avec  prolapsus  de  la 
muqueuse  intestinale.     Revue  d'orthopedie,  1901,  xii,  321. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  213 

Korte:  Ein  Fall  von  Extirpation  des  persist irenden  Ductus  omphalomesentericus.  Deutsche 
med.  Wochenschr.,  1S9S,  xxiv,  103. 

Lannelongue  et  Fremont:  De  quelques  varietes  de  tumeurs  congenitales  de  l'ombilic  et  plus 
specialement  des  tumeurs  adenoides  divert iculaires.     Arch.  gen.  de  med.,  1884,  7.  ser.,  xiii,  36. 

Leisrink  und  Alsberg:  Einklemmung  seit  14  Tagen,  Laparotomie.  Einschntirung  durch  einen 
offen  gebliebenen  Ductus  omphalo-mesaraicus;  Resection  des  eingeschniirten  Darmstiickes 
mit  dem  schniirenden  Strang;  Darmnaht.  Todnach  6  Stunden.  Langenbeck's  Arch.  f.  klin. 
Chir.,  1S82,  xxviii,  768. 

Marshall:  Case  of  Perforate  Umbilicus.     Med.  Times  and  Gaz.,  1868,  ii,  640. 

Morian:  Ueber  das  offene  Meckel'sche  Divertikel.  Langenbeck's  Arch.  f.  klin.  Chir.,  1899,  lviii, 
306. 

Xicaise:  Ornbilic.  Dictionnaire  encyclopedique  des  sciences  medicales,  Paris,  1881,  2.  ser., 
xv5  159. 

Xeurath,.  R. :  Zur  Casuistik  des  persist  irenden  Ductus  omphalo-mesaraicus.  Wien.  klin.  Wochen- 
schr., 1896,  ix,  1158. 

Park,  Roswell:  Clinical  Lecture  on  Congenital  Fistula?  and  Sinuses  at  the  Umbilicus.  Med. 
Fortnightly,  1896,  ix,  9. 

Pernice.  L.:   Die  Xabelgeschwiilste,  Halle,  1892. 

Poussin:  Observation  sur  l'expulsion  de  l'abdomen,  par  une  ouverture  a  l'ombihc,  de  plusieurs 
vers  ascarides-lombricoides.     Jour,  de  med.,  1817,  xl,  81. 

Pratt,  J.  W.:  A  Remarkable  Case  of  Umbilical  Tumor.     The  Lancet,  London,  1884,  ii,  1142. 

Prestat:  Ledderhose,  Chirurgische  Erkrankungen  des  Nabels.  Deutsche  Chirurgie,  1890,  Liefe- 
rung  45  b. 

Quaet-Faslem:   Das  Offenbleiben  des  Ductus  omphalo-mesentericus.     Inaug.  Diss.,  Kiel,  1899. 

Railton,  T.  C:  Prolapse  of  Meckel's  Diverticulum  (Omphalo-mesenteric  Duct).  Brit.  Med. 
Jour.,  1893,  i,  795. 

Roth,  M.:  Ueber  Missbildungen  im  Bereich  des  Ductus  omphalo-mesentericus.  Virchows 
Arch.,  1881,  Lxxxvi,  371. 

Salzer,  H.:  Ueber  das  offene  Meckel'sche  Divertikel.     Wien.  klin.  Wochenschr.,  1904,  xvii,  614. 

Sauer,  F.:  Ein  Fall  von  Prolaps  eines  offenen  Meckel'schen  Divertikels  am  Nabel.  Deutsche 
Zeitschr.  f.  Chir.,  1S96-97,  xhv,  316. 

Schroeder,  G.:  Ueber  die  Divert ikel-Bildungen  am  Darmkanale.  Inaug.  Diss.  (Erlangen),  Augs- 
burg, 1854. 

Shepherd,  F. :  Umbilical  Faecal  Fistula  in  an  Infant  Cured  by  Radical  Operation.  Arch,  of  Pedia- 
trics, 1892,  ix,  55. 

MacSwiney,  S.  M.:  Ascaris  Lumbricoides  extracted  from  an  Umbilical  Fistula.  Proc.  Path. 
Soc.  of  Dublin,  1S73-75,  iv,  251. 

Stierlin,  R.:  Zur  Casuistik  angeborener  Xabelfisteln.  Deutsche  med.  Wochenschr.,  1S97,  xxiii, 
188. 

Wilks,  S.:  Strangulation  of  Intestine  by  Diverticulum  Ilei.  Trans.  Path.  Soc.  London,  1S65, 
xvi,  126. 

Weiss,  Eduard:  Ueber  diverticulare  Xabelhernien  und  die  aus  ihnen  hervorgehenden  Xabelfisteln. 
Inaug.  Diss.,  Giessen,  186S. 


CHAPTER  XI. 
A  PATENT  OMPHALOMESENTERIC  DUCT— (Continued). 

The  opening  of  a  patent  omphalomesenteric  duct  on  the  side  of  the  umbilical  cord  before  the  cord 

drops  off:    Report  of  cases. 
Prolapsus  of  the  bowel  through  a  patent  omphalomesenteric  duct  opening  on  the  side  of  the 

umbilical  cord. 
Escape  of  meconium  into  the  liquor  amnii  through  the  umbilicus. 
An  omphalomesenteric  duct  opening  into  the  abdomen  and  discharging  feces  into  the  abdominal 

cavity. 
A  patent  omphalomesenteric  duct  associated  with  defective  development  of  the  rectum  or  anus. 

In  this  chapter  are  considered  several  cases  of  patent  omphalomesenteric  duct 
that  presented  some  rather  unusual  features. 

THE  OPENING  OF  A  PATENT  OMPHALOMESENTERIC  DUCT  ON  THE  SIDE  OF  THE 
UMBILICAL  CORD  BEFORE  THE  CORD  DROPS  OFF. 

A  glance  at  Fig.  10,  p.  10,  Fig.  11,  p.  11,  Fig.  12,  p.  12,  in  the  chapter  on 
Embryology,  will  show  that  in  the  early  months  of  fetal  life  a  large  part  of  the  intes- 
tine lies  in  the  exoccelomic  cavity  of  the  cord.  As  the  embryo  develops  nearly  all 
the  intestine  is  found  in  the  sac,  but  finally  the  bowel  recedes  into  the  abdomen  and 
this  sac  becomes  obliterated. 

That  the  sac  occasionally  remains  open,  and  contains  a  patent  omphalomesenteric 
duct,  is  clearly  demonstrated  by  the  following  cases: 

Peake,  in  1811,  in  a  new-born  child  observed  a  tumor  at  the  umbilicus.  It  was 
larger  than  a  walnut,  and  the  skin  grew  over  it  for  a  quarter  of  an  inch.  The  tumor 
had  the  appearance  of  intestine  protruding  into  the  umbilical  cord.  The  cord  was 
ligated  at  a  point  three  or  four  inches  from  the  umbilicus.  At  the  lower  part  of 
the  tumor  Peake  noticed  a  fissure,  and  soon  a  thin,  dark  material  escaped  from  the 
opening.  The  child  died  on  the  third  day,  and  at  autopsy  the  ileum  was  found 
protruding  at  the  umbilicus. 

Auvard,  in  1889,  observed  a  tumor  at  the  umbilicus  in  a  newly  born  child, 
Accordingly  the  cord  was  tied  at  a  point  8  cm.  from  the  umbilicus.  The  tumor 
measured  3x4  cm.  In  the  anterior  portion  of  the  cord,  3  cm.  from  the  umbilicus. 
was  an  opening  which  had  everted  margins  and  measured  3  to  4  mm.  It  was  reddish 
in  color,  and  meconium  escaped  from  it.  Both  the  mother  and  the  midwife  said 
this  opening  existed  when  the  child  was  born  (Fig.  127,  p.  216,  Fig.  128,  p.  216). 
The  child's  bowels  moved  regularly,  but  it  sometimes  vomited  fecal  matter. 

When  the  cord  came  away,  a  red  tumor  the  size  of  a  walnut  remained,  which 
was  continuous  with  the  opening.  At  autopsy  a  patent  omphalomesenteric  duct 
was  found  (Fig.  129). 

(iampert,  in  1893,  reported  a  case  in  which  the  cord  was  larger  than  usual.  It 
was  accordingly  tied  at  a  point  9  cm.  from  the  umbilicus.  Five  days  later,  although 
the  cord  was  still  attached,  yellowish  material  began  to  escape  from  its  base.     The 

214 


A    PATENT    OMPHALOMESENTERIC    DUCT.  215 

cutaneous  umbilical  orifice  was  prominent,  and  formed  a  collar  around  the  tumor 
occupying  its  center.  This  tumor  was  1  cm.  in  diameter  and  irreducible,  and  in 
its  center  was  an  orifice  from  which  gas  and  feces  escaped.  A  sound  could  be  car- 
ried for  3  or  4  cm.  into  the  fistula.  The  surrounding  skin  was  slightly  irritated. 
On  the  tenth  day  a  slight  prolapse  of  the  mucosa  occurred.  Fearing  prolapsus  of 
the  bowel,  Gampert  cauterized  the  canal,  applied  a  ligature  to  the  tumor,  cut  off 
the  excess,  and  applied  pressure.     In  this  way  the  fistula  was  successfully  closed. 

Guthrie,  in  1896,  recorded  the  case  of  a  child  that  had  had  no  movement  for 
three  days  after  birth.  Feces  then  began  to  escape  from  an  opening  in  a  colorless, 
bladder-like  projection,  which  had  existed  at  the  umbilicus  since  birth.  This  pro- 
trusion was  attached  to  the  cord.  It  became  red  and  inflamed,  ulcerated,  and  then 
disappeared. 

For  a  month  after  birth  some  feces  were  passed  by  the  rectum,  and  then  all  es- 
caped through  the  umbilicus.  Later  there  occurred  a  prolapse  of  the  bowel  through 
the  opening,  which,  however,  finally  disappeared  spontaneously.  At  autopsy  the 
patent  omphalomesenteric  duct  was  found  at  a  point  12  inches  above  the  ileocecal 
valve. 


CASES  IN   WHICH  THE  OMPHALOMESENTERIC  DUCT  OPENED  ON  THE  SIDE  OF 

THE  UMBILICAL  CORD. 

A  Patent  Omphalomesenteric  Duct  Opening  to  the 
Side  of  the  Umbilical  Cord.*  —  In  this  case  the  midwife  noticed  a 
tumor  at  the  umbilicus.  The  cord  was  tied  distally  to  this,  at  a  point  8  cm.  from 
the  insertion  at  the  umbilicus.  When  the  child  was  seen  by  Auvard,  there  was  a 
cylindric  tumor,  measuring  3x4  cm.,  at  the  umbilicus.  This  was  included  in  the 
membranes  of  the  cord  and  covered  with  amnion.  The  cord  was  free  for  about  6 
cm.  from  the  umbilicus.  In  the  anterior  portion  of  the  cord,  at  a  point  3  cm.  from 
the  umbilicus,  was  an  opening,  the  margins  showing  an  eversion.  This  opening  was 
reddish  in  color;  it  measured  3x4  mm.,  and  from  it  there  escaped  a  greenish  liquid, 
rather  thick,  and  of  the  character  of  meconium.  The  midwife  and  the  mother  said 
that  this  opening  had  existed  at  the  time  of  the  child's  birth  (Figs.  127  and  128). 
The  bowels  moved  regularly.     All  the  generative  organs  were  normal. 

This  boy  was  transferred  on  the  fourth  of  January  to  La  Charit?.  By  January 
8th  the  cord  had  not  yet  come  away,  but  a  small  quantity  of  greenish  liquid  was  es- 
caping from  the  opening.  The  discharge  was  sometimes  yellowish.  The  patient 
vomited  frequently,  and  the  fecal  matter  was  sometimes  green.  On  January  10th 
the  cord  came  away,  leaving  a  red  tumor,  the  size  of  a  walnut,  continuous  with 
the  opening  above  described.  A  sound  introduced  could  be  passed  into  the  cavity 
without  difficulty,  and  carried  inward  6  cm.  The  child's  weight  continually 
diminished. 

On  January  12th  the  child  was  presented  at  the  Obstetrical  and  Gynecological 
Society  of  Paris.  The  members  present,  particularly  Lucas-Championniere,  were 
of  the  opinion  that  the  tumor  represented  a  hernia  of  the  diverticulum  of  the  intes- 
tine. The  child's  weight  continued  to  diminish,  and  he  died  on  February  3d, 
apparently  from  weakness.  The  umbilical  tumor  had  diminished  in  size.  At 
autopsy  it  was  not  larger  than  a  pea.     When  the  abdomen  was  opened,  a  loop  of 

*  Auvard:   Travaux  d'obstetrique,  1889,  Paris,  i,  331. 


216 


THE    UMBILICUS    AND    ITS    DISEASES. 


small  bowel  was  found  extending  toward  the  umbilicus,  and  a  diverticulum  opened 
from  the  loop  through  the  umbilicus  (Fig.  129).  The  diverticulum  entered  the 
small  bowel  at  a  point  42  cm.  from  the  cecum. 

A  Patent  Omphalomesenteric  Duct  Opening  on  the 
Side  of  the  Umbilical  Cord.*  — •  The  cord  at  the  umbilicus  was 
larger  than  usual.  The  ligature  was  applied  at  a  point  9  cm.  from  the  umbilicus. 
On  February  loth,  five  days  after  birth,  the  midwife  called  Gampert,  because  the 
cord  did  not  come  away  and  because  at  its  base  a  yellowish  material  was  escaping. 
This  discharge  resembled  fecal  matter.     The  stools  passed  normally  by  the  rectum. 


Fig.  127. — A  Patent  Omphalomes- 
enteric Duct  Opening  at  the 
Base  or  the  Umbilical  Cobd. 
(After  Auvard.) 
This  sketch  was  made  four  days 
after  the  birth  of  the  child.     The 
cord  was  ligated  at  a  point  about  8 
cm.  from  the  umbilicus.     In  the  an- 
terior part  of  the  cord,  3  cm.  from 
the  umbilicus,  was  an  opening  ad- 
mitting the  little  finger.     The  mar- 
gins were  raised,  and  there  was  some 
eversion,  the  everted  portion  being 
reddish  in  color.     From  the  orifice  a 
greenish  material,  having  the  char- 
acteristics  of   meconium,    escaped. 
There  was  frequent  vomiting. 


Fig.    128. — A    Patent    Om- 
phalomesenteric Duct. 
(After  Auvard.) 
This  picture  was  obtained 
eleven  days  after  birth.     The 
cord  came  away  on  the  seventh 
day,  and  left  a  pinkish  tumor 
the  size  of  a  walnut,  with  the 
opening  as  shown.     The  child 
became  weaker,  and  died  after 
a  month.     For  the  appearance 
four  days  after  birth  see  Fig. 
127.    For  the  intra-abdominal 
picture  see  Fig.  129. 


Fig.  129. — A  Patent  Omphalomesen- 
teric Duct  as  Seen  fbom  the 
Abdominal  Cavity.  (After  Au- 
vard.) 

This  picture  was  obtained  at  au- 
topsy. A  loop  of  small  bowel  lies  near 
the  inner  umbilical  opening,  and  from 
it  a  diverticulum  passes  directly  to  the 
umbilicus.  It  opened  on  the  surface. 
Passing  from  the  mesentery  over  loops 
of  small  bowel  to  the  umbilicus  was  a 
fine  fibrous  cord,  evidently  a  remnant 
of  an  omphalomesenteric  vessel. 


When  seen,  the  child  was  large  and  well  developed,  and  the  cord  was  still  adher- 
ent to  one-half  of  the  circumference  of  the  umbilicus.  The  cutaneous  umbilical 
orifice  was  prominent,  and  formed  a  large  collar  around  the  tumor  which  occupied 
the  center.  This  tumor  was  about  the  size  of  the  little  finger,  and  cylindric  in  form 
and  shape.  It  was  1  cm.  in  diameter  and  irreducible.  It  had  in  its  center  an  ori- 
fice from  which  yellowish  material  and  gas  escaped.  A  sound  could  be  carried  in 
to  a  depth  of  3  or  4  cm.     The  skin  around  the  umbilicus  was  slightly  irritated. 

On  the  tenth  day,  when  the  child  cried,  a  slight  prolongation  of  the  mucosa 
showed  at  the  orifice.     Fearing  prolapsus  of  the  bowel,  Gampert  cauterized  the 

*  Gampert:  Fistule  entcTo-ombilicale  diverticulaire  chez  un  nouveau-ne.  Rev.  med.  de  la 
Suisse  romande,  1893,  xiii,  356. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  217 

canal  and  used  pressure.  The  tumor  diminished,  and  tannic  acid  powder  and 
vaselin  were  used.  A  silk  ligature  was  applied,  and  the  excess  of  tissue  was  cauter- 
ized.    When  the  ligature  came  away,  the  opening  was  closed  and  remained  so. 

A  Case  of  Patent  Meckel's  Diverticulum  into  which 
the  Posterior  or  Distal  Wall  of  the  Ileum  Became  Intus- 
su  seep  ted,  Forming  an  Umbilical  Tumor;  Death.*  —  A 
male  infant,  six  weeks  old,  was  admitted  to  the  Paddington  Green  Hospital  on 
April  25,  1892.  At  birth  it  weighed  seven  pounds  and  three  ounces.  After  three 
days,  during  which  there  was  no  stool,  the  child  began  to  defecate  through  an  open- 
ing in  a  colorless,  bladder-like  projection,  which  had  existed  from  birth  at  the 
umbilicus  and  to  which  the  cord  was  attached.  The  cord  separated  on  the  ninth 
day. 

The  colorless  protrusion  subsequently  became  red  and  inflamed  and  finally 
ulcerated;  it  disappeared  a  few  days  before  admission.  For  about  a  month  after 
birth  some  portion  of  the  feces  came  from  the  rectum,  but  later  all  passed  through 
the  umbilicus.     Micturition  was  normal. 

On  admission  the  child  was  puny  and  emaciated.  Protruding  from  the  umbilicus 
was  an  elongated  mass,  V/2  inches  long  by  1  inch  in  breadth.  It  was  of 
a  dull  red  color,  and  had  the  appearance  of  intestinal  mucosa.  Near  its  superior 
extremity  there  was  an  opening  through  which  feces  were  discharged,  and  a 
catheter  could  be  passed  upward  and  to  the  right.  There  was  also  a  small  dimple 
on  the  inferior  end  of  the  protrusion.     This  would  not  admit  a  probe. 

On  April  29th  the  protrusion  increased  to  the  length  of  six  inches.  It  became 
somewhat  tightly  constricted  at  the  umbilicus.  It  was  much  congested,  and 
resembled  an  intussusception.     Taxis  failed. 

As  the  patient  was  too  weak,  the  hernia  was  let  alone.  Two  days  later  it 
disappeared  spontaneously,  but  the  child  died  of  exhaustion  May  2d. 

Autopsy. — The  fistula  was  12  inches  above  the  ileocecal  valve.  The  upper 
opening  led  to  the  somewhat  dilated  ileum;  the  lower  opening  to  the  collapsed 
small  and  large  bowel.  The  entire  large  bowel  was  not  bigger  than  a  lead-pencil. 
The  cecum  was  reduced  to  the  size  of  the  first  joint  of  the  little  finger.  The  large 
bowel  apparently  had  never  contained  feces.  There  had  been  a  prolapsus  of  the 
bowel  through  the  patent  omphalomesenteric  duct. 

Case  of  Preternatural  Anus  Found  in  a  Portion  of 
Ileum  Protruded  at  the  Umbilicus. — J.  Peake,f  a  member  of 
the  Royal  College  of  Surgeons,  London,  found,  on  delivering  a  woman  of  a  healthy- 
looking  boy,  that  the  child  had  a  tumor  at  the  umbilicus.  This  was  larger  than  a 
walnut,  and  the  skin  grew  over  it  for  a  quarter  of  an  inch.  At  the  upper  part  the 
umbilical  vessels  passed  over  the  tumor  but  seemed  altogether  distinct  from  it. 
A  ligature  was  tied  around  the  cord  where  it  appeared  normal,  that  is,  at  a  point 
three  or  four  inches  from  the  umbilicus. 

Peake  goes  on  to  say  that  the  tumor  had  the  appearance  of  a  protruding  portion 
of  the  intestine  within  the  umbilical  cord,  and  at  its  lower  part  he  could  observe  a 
fissure.  Soon  a  thin,  dark  material  escaped  from  this  opening;  it  was  probably 
meconium. 

Shortly  after  birth  the  child  vomited  frequently,  and  was  evidently  ill.     It 

*  Guthrie,  L.  G.:  Pediatrics,  1896,  ii,  1. 

t  Peake,  J.:  Edinb.  Med.  and  Surg.  Jour.,  1811,  vii,  52. 


218  THE    UMBILICUS    AND    ITS    DISEASES. 

had  many  convulsions,  and  died  on  the  third  day.  The  food  that  was  given  it  was 
either  directly  brought  up  again  or  afterward  passed  through  the  aperture  at  the 
navel.  Nothing  seemed  to  pass  along  the  regular  course  of  the  intestine.  Just 
before  death  a  little  mucus  and  meconium  escaped  by  the  rectum. 

Autopsy. — The  passage  from  the  stomach  to  the  umbilicus  was  normal.  A 
portion  of  the  ileum  protruded  at  the  umbilicus.  The  bowel  below  was  much 
smaller  than  normal. 

PROLAPSUS  OF  THE  BOWEL  THROUGH  A  PATENT  OMPHALOMESENTERIC  DUCT 
OPENING  ON  THE  SIDE  OF  THE  UMBILICAL  CORD. 

Prolapsus  of  the  bowel  through  a  patent  omphalomesenteric  duct  is  discussed 
at  length  in  Chapter  XII.  The  case  recorded  by  Gibb  is  the  only  example  known 
to  me  in  which  prolapsus  of  the  bowel  occurred  on  the  side  of  the  cord  during  the 
first  few  hours  of  life.  In  Guthrie's  case  the  omphalomesenteric  duct  opened  on 
the  side  of  the  cord,  but  prolapsus  did  not  occur  until  several  weeks  after  the  cord 
came  away. 

Unique  Congenital  Malformation,  Associated  with 
Umbilical  Hernia  and  a  Pendulous  Artificial  Anus.— 
Gibb  *  reports  a  rather  unusual  condition  noted  a  few  hours  after  the  child's  birth. 
The  upper  part  of  the  cord  had  dilated,  forming  an  umbilical  hernia  containing 
intestine.  Attached  to  the  side  of  the  sac  was  a  blood-red  body  with  villous  sur- 
faces, looking  like  intestinal  mucous  membrane.  Meconium  passed  from  both 
ends  of  this  body.  From  the  anus  feces  passed  on  the  third  day.  At  autopsy  the 
large  bowel  was  found  to  be  diminished  in  size.  Gibb  thought  that  the  mass  was 
a  portion  of  the  cecum  and  the  ileum.  [This  picture  (Fig.  130)  presents  the  appear- 
ances typical  of  a  prolapse  or  inversion  of  the  small  bowel  through  the  patent 
omphalomesenteric  duct  in  association  with  an  umbilical  hernia.] 

ESCAPE  OF  MECONIUM  INTO  THE  LIQUOR  AMNII  THROUGH  THE  UMBILICUS. 

If  Auvard  had  been  present  when  the  child,  whose  case  he  reported,  was  born, 
he  would  probably  have  found  meconium  in  the  liquor  amnii,  as  the  omphalo- 
mesenteric duct  lay  open  on  the  side  of  the  cord.  In  other  words,  at  birth  there 
was  a  direct  connection  between  the  lumen  of  the  small  bowel  and  the  amniotic 
cavity. 

The  only  case  in  which  it  is  definitely  stated  that  meconium  escaped  through 
the  cord  into  the  liquor  amnii  is  the  one  mentioned  by  Brindeau. 

A  Patent  Omphalomesenteric  Duct,  with  Fecal  Mat- 
ter Escaping  into  the  Liquor  Amnii.  f  —  The  patient,  an  eight 
months  child,  died  on  the  fifth  day  after  birth.  Its  weight  was  two  pounds  and 
three  ounces.  Meckel's  diverticulum  was  22  cm.  above  the  cecum.  The  ompha- 
lomesenteric duct  was  open,  and  traction  had  drawn  the  gut  outward  at  a  sharp 
angle.  The  portions  of  the  intestine  immediately  above  and  below  the  duct  were 
thus  easily  drawn  together,  like  the  barrel  of  a  fowling-piece. 

Meconium  before  birth  had  passed  into  the  liquor  amnii.  The  intestine  above 
the  diverticulum  was  dilated;  below,  it  was  very  small. 

*  Gibb:  Trans.  Path.  Soc.  London,  1856,  vii,  216. 

t  Brindeau:  Nouv.  arch,  d'obstet.  et  de  gyn.,  Fevrier  25,  1895,  45. 


A    PATENT    OMPHALOMESENTERIC    DUCT. 


219 


AN  OMPHALOMESENTERIC  DUCT  OPENING  INTO  THE  ABDOMEN  AND  DISCHARG- 
ING FECES  INTO  THE  ABDOMINAL  CAVITY. 

Weiss*  said:   "Notwithstanding  the  fact  that  in  dead-born  children  diverticula 
are  found  in  the  umbilical  cord,  there  has  been  no  example  of  death  due  to  an  out- 


Fig.  130. — Inversion  of  the  Bowel  Through  a  Patent  Omphalomesenteric  Duct  Opening  on  the  Side  or  the 

Umbilical  Cord.     (Redrawn  after  Gibb.) 
At  a  is  a  hernial  dilatation  of  the  cord.     This  sac  was  filled  with  intestines.     At  6  is  the  opening  of  a  patent  omphalo- 
mesenteric duct.     Through  this  the  small  bowel  had  prolapsed,  turning  inside  out.     At  c  and  d  are  the  bowel  open- 
ings.    As  the  bowel  had  turned  inside  out,  its  mucosa  was,  of  course,  congested  and  dark  red. 


pouring  of  fecal  matter  into  the  abdominal  cavity."  This  was  probably  true  at 
that  date,  but  Orthf  says:  "I  recently  made  an  autopsy  on  a  new-born  child  and 
found  a  diverticulum  split  longitudinally  below  the  umbilicus  and  adherent  to  the 

*  Weiss:  Inaug.  Diss.,  Giessen,  1868. 

t  Orth:  Lehrbuch  der  spec.  path.  Anatomie,  Berlin,  1887,  i,  765. 


220  THE    UMBILICUS    AND    ITS    DISEASES. 

anterior  abdominal  wall  in  such  a  manner  that  meconium  could  escape  into  the 
abdominal  cavity.  A  large  quantity  of  meconium  lay  between  the  abdominal  wall 
and  the  thickened  omentum." 


LITERATURE  CONSULTED  ON  THE  OPENING  OF  THE  PATENT  OMPHALOMESEN- 
TERIC DUCT  ON  THE  SIDE  OF  THE  UMBILICAL  CORD  OR  IN  THE 
ABDOMINAL  CAVITY. 

Auvard:  Travaux  d'obstetrique,  1889,  Paris,  i,  331. 

Brindeau:  Nouv.  arch,  d'obstet.  et  de  gyn.,  Fevrier  25,  1895,  45. 

Gampert:  Fistule  entero-ombilicale  divert  iculaire  chez  un  nouveau-ne.  Rev.  med.  de  la  Suisse 
romande,  1893,  xiii,  356. 

Gibb:  Unique  Congenital  Malformation  Associated  with  Umbilical  Hernia  and  a  Pendulous  Arti- 
ficial Anus.     Trans.  Path.  Soc.  London,  1856,  vii,  216. 

Guthrie,  L.  G. :  A  Case  of  Patent  Meckel's  Diverticulum  into  which  the  Posterior  or  Distal  Wall 
of  the  Ileum  became  Intussuscepted,  forming  an  Umbilical  Tumor.  Death.  Pediatrics, 
1896,  ii,  1. 

Peake,  J.:  Case  of  Preternatural  Anus  found  in  a  Portion  of  Ileum  protruded  at  the  Umbilicus. 
Edinburgh  Med.  and  Surg.  Jour.,  1811,  vii,  52. 

Weiss,  E.:  Ueber  diverticulare  Nabelhernien  und  die  aus  ihnen  hervorgehenden  Nabelfisteln. 
Inaug.  Diss.,  Giessen,  1868. 


A  PATENT  OMPHALOMESENTERIC  DUCT  ASSOCIATED  WITH  DEFECTIVE  DEVELOP- 
MENT OF  THE  RECTUM  OR  ANUS. 

Anderson's  patient  was  a  child  born  at  the  seventh  month.  There  was  no  anus, 
and  the  rectum  and  sigmoid  were  lacking.  The  omphalomesenteric  duct  was 
patent. 

Cheyne's  patient  was  a  three-weeks -old  child.  The  omphalomesenteric  duct 
was  patent.  The  anus  ended  in  a  blind  pouch,  one  inch  within  the  sphincter.  The 
child  was  still  alive  when  the  case  was  reported  to  the  medical  society. 

Nicolas's  patient  was  a  child  six  days  old.  The  omphalomesenteric  duct  was 
patent.     The  anus  was  open,  but  an  obstruction  was  found  several  inches  above  it. 

A  Case  of  Fecal  Fistula  at  the  Umbilicus  with  Non- 
development  of  the  Sigmoid  Flexure  and  Rectum.*  — 
The  patient  was  a  male  child  delivered  at  the  seventh  month.  After  tying  and 
cutting  the  cord,  the  physician  noticed  a  red  tumor  of  nevoid  aspect  at  the  line  of 
section,  and  perceived  that  the  proximal  end  of  the  cord  was  considerably  enlarged. 
On  the  following  day  meconium  escaped  from  the  umbilical  stump.  There  was  no 
trace  of  an  anal  orifice.  The  edges  of  the  umbilical  orifice  became  red  and  everted. 
The  child  lost  flesh,  and  died  on  the  twenty-third  day  after  birth. 

At  autopsy  prolapsus  of  the  ileum  through  the  umbilicus  was  found.  This  was 
134  inches  from  the  cecum.  The  short  portion  of  the  ileum  extending  to  the  cecum 
was  empty.     The  sigmoid  and  rectum  were  wanting. 

[The  opening  undoubtedly  represented  a  patent  omphalomesenteric  duct.] 

A  Patent  Omphalomesenteric  Duct  Associated  with 
an  Imperforate  Rectum.  — •  Mr.  Cheyne  f  showed  an  infant,  aged  three 
weeks,  with  congenital  umbilical  fecal  fistula,  and  asked  for  suggestions  as  to  treat- 
ment.    The  child  was  rapidly  losing  weight.     The  anus  was  present,  and  a  sound 

*  Anderson,  William:  Trans.  Path.  Soc.  London,  1891,  xlii,  128. 

f  Cheyne,  Watson:   Umbilical  Fecal  Fistula.  Brit.  Med.  Jour.,  1892,  i,  815. 


A    PATENT    OMPHALOMESENTERIC    DUCT.  221 

passed  in  about  an  inch.  The  umbilical  aperture  seemed  to  lead  into  a  canal. 
The  general  impression  seemed  to  be  that  operative  intervention  was  undesirable. 

Patent  Omphalomesenteric  Duct  Associated  with 
an  Imperforate  Sigmoid. — -Nicolas*  (Obs.  12)  refers  to  a  boy  six 
days  old  who  was  observed  in  Marjolin's  clinic.  At  birth  there  was  a  purulent 
discharge  from  the  umbilicus,  and  nothing  had  passed  by  bowel.  The  child  had 
vomited  fecal  matter  several  times.  On  rectal  examination  the  anus  was  found  to 
be  patent,  but  there  was  an  obstruction  at  a  point  several  centimeters  higher  up, 
so  that  not  even  gas  could  be  expelled  by  the  rectum.  Two  days  later  an  artificial 
anus  was  made,  but  the  child  died  forty-eight  hours  later. 

Autopsy. — -The  small  bowel  was  large  for  so  young  a  child.  At  a  point  80  cm. 
from  the  pylorus  it  was  23^  times  the  normal  in  diameter.  It  suddenly  dilated  and 
became  4  to  5  cm.  in  diameter.     Meckel's  diverticulum  was  3  cm.  long. 

Had  it  not  been  for  the  open  omphalomesenteric  duct  these  children  would  have 
succumbed  a  few  days  after  birth.  The  open  duct  was  in  reality  a  safety  valve. 
For  those  desiring  a  more  extended  knowledge  of  the  subject  of  patent  omphalo- 
mesenteric duct  associated  with  faulty  development  of  the  bowel,  a  careful  perusal 
of  Ahlfeld's  splendid  monograph  is  to  be  recommended. 

In  these  cases  it  would  be  necessary  to  establish  the  continuity  of  the  bowel 
before  attempting  to  remove  the  omphalomesenteric  duct. 

*  Nicolas,  P. :  Sur  deux  varietes  de  fistules  ombilicales,  Paris,  1883. 


LITERATURE  CONSULTED 

ON  PATENT  OMPHALOMESENTERIC  DUCT  ASSOCIATED  WITH  DEFECTIVE  DEVELOPMENT  OF  THE 

RECTUM  OR  ANUS. 

Anderson,  Wm.:  A  Case  of  Fecal  Fistula  at  the  Umbilicus  with  Non-development  of  the  Sigmoid 

Flexure  and  Rectum.    Trans.  Path.  Soc.  London,  1891,  xlii,  128. 
Cheyne,  Watson:  Umbilical  Fecal  Fistula.  Brit,  Med.  Jour.,  1892,  i,  815. 
Nicolas,  P.:  Sur  deux  varietes  de  fistules  ombilicales,  Paris,  1883. 
Ahlfeld:  Zur  yEtiologie  der  Darmdefecte  und  der.  Atresia  ani.     Arch.  f.  Gyn.,  1873,  v,  230. 


CHAPTER  XII. 

PROLAPSUS  OF  THE  BOWEL  THROUGH  A  PATENT  OMPHALOMESEN- 
TERIC DUCT. 

Historic  sketch. 

Prolapsus  of  the  bowel. 

Results. 

Findings  at  autopsy. 

Cases  of  prolapsus  of  the  bowel  through  a  patent  omphalomesenteric  duct. 

In  1843  King  reported  an  observation  made  by  Parsons  and  Gunthorpe  in 
which  the  small  bowel  had  prolapsed  through  a  patent  omphalomesenteric  duct 
and  was  recognized  as  a  sausage-like  mass  lying  on  the  abdomen  in  the  umbilical 
region.  From  time  to  time  since  then  an  isolated  case  has  been  observed.  We 
shall  now  refer  briefly  to  certain  conditions  which  may  be  found  associated  with 
this  abnormality. 

The  Cord.  —  In  some  of  these  cases,  when  the  child  is  born,  the  cord  near 
the  umbilicus  is  unusually  thick.  In  one  case,  reported  by  Gesenius,  this  thickened 
area  gave  a  crackling  sensation  when  it  was  grasped  between  the  fingers. 

Age.  —  The  condition  has  been  noted  as  early  as  the  third  day  and  as  late 
as  six  months  after  birth.  In  nearly  half  of  the  cases  it  occurred  within  the  first 
two  weeks.  In  Lowenstein's  case  the  child  was  three  months  old;  in  Helweg's, 
four  months;  in  Kolbing's,  nineteen  weeks;  in  Huttenbrenner's  and  in  Wein- 
lechner's  case,  five  months,  and  in  Blin's  case,  six  months. 

Development  of  the  Umbilical  Fistula.  —  In  considering 
these  cases  we  must  remember  that  the  omphalomesenteric  duct  has  remained 
patent  from  the  intestine  through  the  umbilicus,  and  out  for  a  variable  distance 
into  the  cord.  If  it  has  remained  open  to  the  point  where  the  cord  has  been  tied 
off,  of  course,  a  fecal  fistula  will  be  present  just  as  soon  as  the  cord  drops  off.  When 
the  fistulous  tract  is  very  small,  it  may  be  impossible  for  feces  to  escape  for 
some  days.  Should  the  duct  be  patent  just  to  the  umbilicus,  a  small  umbilical 
polyp  may  present  itself  in  the  umbilical  depression  and  no  fistula  will  for  the  time 
being  be  noted. 

It  may  be  interesting  to  trace  the  development  of  the  fistula  in  the  individual 
cases. 

In  Barth's  case,  when  the  cord  came  away,  there  was  a  red  nodule  1  cm.  in 
diameter  at  the  umbilicus,  and  in  the  center  of  this  a  fistula,  into  which  a  probe  could 
be  introduced  for  4  cm. 

In  Gesenius's  case  a  small  polyp  was  noted  when  the  cord  came  away.  Next  day 
this  showed  an  opening  in  its  center,  and  two  days  later  the  projection  had  increased 
in  size  and  looked  like  a  raspberry.  The  opening  now  admitted  a  catheter  for  six 
or  seven  inches,  and  feces  escaped  from  it . 

In  Gevaert's  and  in  Golding-Bird's  cases  the  fistula  was  noted  when  the  cord 
came  away. 

222 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     223 

In  Basevi's  case,  when  the  cord  dropped  off,  it  was  apparent  that  the  umbilicus 
had  not  healed,  a  reddish,  moist  wound  remaining.  Feces  did  not  escape  until 
later. 

In  Lowenstein's  case,  after  the  cord  came  away,  an  "inflammation"  was  noted  at 
the  umbilicus.  On  the  fourteenth  day  a  fistula  developed.  Lowenstein  urged 
operation,  which  was  refused.  Later  the  opening  became  as  large  as  a  50-pfennig 
piece,  and  three  weeks  after  this  as  large  as  a  plum. 

In  Arndt's  and  in  Ophuls's  case  a  small  umbilical  polyp  was  found  in  addition  to 
the  fistula,  and  in  Blin's  case  there  were  two  small  polyps  as  well  as  a  minute  fistulous 
opening. 

In  Theremin's  Case  1  the  cord  came  away  on  the  eleventh  day.  In  the  center 
of  the  umbilical  ring  was  a  reddish  tumor,  conic  in  form,  and  resembling  an  umbil- 
ical polyp.  There  were  small  ulcers  on  the  surface  of  the  tumor,  and  on  the 
twenty-third  day  a  superficial  hemorrhage  occurred. 

In  Theremin's  Case  2  the  cord  came  away  on  the  eighth  day,  leaving  at  the  umbil- 
icus a  conic  red  polyp,  1.5  cm.  long  and  1  cm.  broad.  There  was  no  vestige  of  an 
opening.  Twelve  days  later  the  polyp  had  receded;  it  was  not  over  5  mm.  long, 
but  had  an  ulcer  in  its  center,  from  which  a  few  drops  of  blood  escaped.  On  the 
following  day  the  polyp  showed  a  small  central  opening. 

In  Holmes'  patient,  who  was  born  prematurely,  the  umbilical  cord  bifurcated 
three  inches  from  the  abdomen.  It  was  tied  off  below  the  bifurcation.  A  fecal 
fistula  was  noted  after  two  weeks. 

In  the  following  cases  a  small  reddish  tumor  had  been  noted  at  the  umbilicus, 
but  the  fistula  did  not  develop  until  this  umbilical  polyp  had  been  tied  off. 

Helweg's  patient,  a  boy  four  months  old,  had  a  penis-like  tumor  at  the  umbilicus. 
This  was  not  present  at  his  birth.  It  was  covered  with  mucosa,  and  had  in  its 
center  a  canal  into  which  a  sound  could  be  introduced,  but  no  feces  escaped  from 
it.  The  tumor  was  tied  off  with  silk.  It  became  necrotic  in  four  days;  shortly 
after  prolapsus  of  the  bowel  was  noted. 

In  King's  case  an  umbilical  polyp  was  removed  by  means  of  caustics.  When 
it  came  away  feces  escaped. 

In  Robbing's  case  a  polyp  existed  at  the  umbilicus.  This  was  tied  off  and 
removed.     Later  there  was  prolapsus  of  the  bowel  through  the  patent  duct. 

From  the  evidence  here  adduced  it  is  perfectly  clear  that  in  some  cases  the  fecal 
fistula  develops  just  as  soon  as  the  cord  comes  away.  If  the  opening  be  of  sufficient 
caliber,  feces  escape  readily,  but  if  very  small,  only  mucus  may  be  discharged  for 
a  time.  In  other  cases  the  outer  end  of  the  omphalomesenteric  duct  has  not  ex- 
tended to  the  point  at  which  the  cord  has  been  ligated,  but  as  a  result  of  ulceration 
or  gangrene  the  intervening  barrier  may  be  broken  down  and  the  fistula  established. 
In  a  few  cases  the  removal  of  the  umbilical  polyp  has  been  sufficient  to  establish 
a  patent  vitelline  duct. 

PROLAPSUS  OF  THE  BOWEL. 

Inversion  of  the  bowel  does  not  necessarily  follow  when  a  patent  omphalo- 
mesenteric duct  exists.  This  will  be  clearly  seen  if  the  reader  refers  to  Chapter  X 
on  Patent  Omphalomesenteric  Duct  (p.  188).  In  that  chapter  are  recorded  a  large 
number  of  cases  in  which  the  bowel  manifested  no  tendency  to  prolapse. 

Several  factors  are  probably  necessary  to  bring  about  prolapsus:    (1)  a  duct 


224 


THE    UMBILICUS    AND    ITS    DISEASES. 


that  is  of  good  caliber  throughout,  or  at  least  at  its  intestinal  attachment;  (2)  an 
excessive  amount  of  abdominal  pressure,  such  as  is  produced  by  crying  or  by  the 
paroxysms  of  whooping-cough,  as  was  noted  in  Hiittenbrenner's  case,  or  by  the 
cough  of  a  bronchitis,  as  was  noted  in  the  case  recorded  by  King.     Whether  a 


Fig.    131. — Patent    Omphalomesenteric    Duct    of 
Large  Diameter 

The  lumen  of  this  duct  is  directly  continuous  with 
that  of  the  small  bowel,  and  at  the  umbilicus  its  intes- 
tinal lining  extends  out  a  short  distance  upon  the  sur- 
face of  the  umbilicus.  When  the  lumen  of  the  omphalo- 
mesenteric duct  is  wide,  there  is  always  great  danger  of 
the  bowel  prolapsing  and  turning  inside  out  through  the 
duct,  following  the  direction  indicated  by  the  arrows. 
For  the  subsequent  stages  of  such  a  prolapsus  see  Figs. 
132,  133,  134,  and  135. 


Fig.  133. — Partial  Prolapsus  of  the  Small  Bowel 
through  the  omphalomesenteric  duct. 
The  wedge  of  small  bowel  has  extended  partly 
through  the  abdominal  wall.  The  loop  is  now  divided 
into  two  definite  portions,  the  dilated  and  proximal,  and 
the  contracted  and  distal  portion.  The  proximal  por- 
tion is  naturally  dilated,  because  there  is  already  a  bar- 
rier to  the  adequate  escape  of  the  fecal  contents.  The 
distal  portion  is,  of  course,  contracted,  because  nothing 
is  passing  into  it.  For  the  subsequent  steps  of  the  pro- 
lapsus see  Figs.  134  and  135. 


Fig.  132. — Commencing  Prolapsus  of  Small  Bowel 
through  Patent  Omphalomesenteric  Duct. 
The  lumen  of  the  duct  is  large,  and  the  small  bowel, 
on  its  mesenteric  side,  is  forming  a  wedge,  as  indicated 
by  the  arrow.  This  wedge  will  gradually  pass  out 
through  the  duct,  as  shown  in  Figs.  133,  134,  and  135. 


Fig.  134. — Prolapsus  of  the  Small  Bowel  through 
the  Patent  Omphalomesenteric  Duct. 
The  small  bowel  has  prolapsed  still  farther  through 
the  omphalomesenteric  duct.  The  proximal  loop  has 
become  more  distended,  and  the  distal  loop  has  become 
contracted  still  more.  The  lumina  of  both  loops  can 
be  traced  out  to  the  surface  of  the  abdomen.  The  mu- 
cosa of  the  bowel  has  now  extended  out  so  far  that  it 
forms  a  definite,  roundish  projection,  elevated  above 
the  surface  of  the  abdomen,  and  naturally  covered  over 
with  intestinal  mucosa,  because  it  is  the  inner  surface  of 
the  small  bowel.  Between  the  proximal  and  distal  con- 
tracted loops  of  bowel  the  peritoneum  is  carried  out- 
ward beyond  the  level  of  the  abdomen,  as  indicated  by 
x.  At  this  stage  only  a  small  amount  of  fecal  matter 
can  escape  from  the  umbilicus,  and  signs  of  obstruction 
will  soon  develop.     For  complete  prolapsus  see  Fig.  135. 


weakly  and  emaciated  child  is  more  prone  to  the  prolapsus  is  problematic,  as  some 
of  the  patients  were  strong,  others  very  frail. 

Just  prior  to  the  prolapsus  some  of  the  children  have  had  stoppage  of  the  bowel 
for  several  days.  In  other  cases  the  first  intimation  of  alarming  trouble  was  the 
presence  of  the  inverted  bowel  on  the  abdomen.  A  careful  study  of  Figs.  131, 
132,  133,  134,  135,  and  136  will  clearly  show  the  reader  the  various  stages  in  the 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     225 

development  of  the  prolapsus  of  the  bowel  through  the  patent  omphalomesenteric 
duet. 

A  glance  at  Fig.  137,  p.  227,  Fig.  138,  p.  228,  Fig.  140.  p.  230,  and  Fig.  141,  p. 
232,  will  give  a  very  good  idea  of  the  prolapsed  bowel.  Lying  on  the  surface  of  the 
abdomen  is  a  red  or  dark-red,  sausage-like  mass.  This  may  lie  transversely  on  the 
abdomen;  it  may  be  S-shaped,  or  appear  as  two  horns  forming  a  semicircle,  as  in 
Theremin's  Case  1.  The  mass  varies  in  length  from  a  few  inches  to  one  and  a  half 
feet,  as  noted  in  Violbing's  case.  As  the  tumor  is  nothing  more  than  a  portion  of 
the  small  bowel  that  has  turned  inside  out  through  the  fistula,  its  surface  consists 
of  intestinal  mucosa.     At  each  end  is  an  opening;  these  represent  the  upper  and 


^   / 


sfcai 


Fig.  135. — Complete  Prolapsus  of  the 
Bowel  through  the  Patent  Omphalo- 
mesenteric Duct. 

For  the  early  stages  of  the  prolapsus  see 
Figs.  131,  132,  133,  and  134.  The  proximal  loop 
of  bowel  is  now  markedly  distended,  and  the  dis- 
tal loop  is  correspondingly  small.  Lying  on  the 
surface  of  the  abdomen  is  a  sausage-shaped 
mass.  This  is  naturally  reddish  or  dark  red  in 
color,  because  it  is  covered  over  with  the  mucosa 
of  the  small  bowel.  It  has  an  upper  opening  cor- 
responding to  the  lumen  of  the  proximal  loop  of 
small  bowel,  and  a  lower  opening — the  lumen  of 
the  distal  loop  of  bowel.  A  loop  of  small  bowel 
is  trying  to  pass  outward  in  the  chink  between 
the  proximal  and  distal  loops,  as  indicated  by 
the  arrow.  That  this  can  take  place  is  shown 
in  Fig.  136. 


Fig.   136. — Prolapsus  of  the  Small  Bowel  through  the 
Patent  Omphalomesenteric  Duct,  and  ajn-  Umbilical 
Hernia  Between  the  Loops  of  Prolapsed  Bowel. 
In  order  that  the  reader  may  satisfactorily  unravel  this  pic- 
ture, he  should  consult  Figs.  131,  132,  133,  134,  and  especially 
135.     The  loop  of  small  bowel  that  in  Fig.  135  was  near  the 
chink  between  the  distal  and  proximal  loops  has  now  succeeded 
in  passing  between  them  and  occupies  the  cavity  (x)  noted  in 
that  picture.     The  lumina  of  the  distended  and  contracted  loops 
are  visible,  and  the  now  enlarged  and  rounded  mass  would  give 
a  note  of  tympany.     The  interloping  loop  of  bowel,  as  a  result 
of  its  constriction,  now  has  a  distended  and  contracted  portion. 


lower  ends  of  the  lumen  of  the  bowel.  Usually  the  openings  are  very  small,  but 
in  Weinlechner's  case  they  were  large  enough  to  admit  the  tip  of  the  finger.  Where 
the  prolapsus  is  small,  the  picture  reminds  one  very  much  of  a  prolapsus  of  the 
rectum  or  of  an  intussusception.  The  tumor  is  usually  elastic  to  the  touch  and 
tends  to  bleed  on  manipulation. 

If  the  child  lives  long  enough,  the  mucosa  covering  the  prolapsed  bowel  may 
become  necrotic.  The  children,  however,  usually  soon  go  into  a  state  of  collapse, 
and  die  in  from  a  few  hours  to  two  or  three  days.  After  the  prolapsus  has  developed, 
nothing  but  mucus  escapes  by  the  rectum.  There  is  in  reality  complete  obstruc- 
tion of  the  bowel,  as  practically  nothing  can  escape  through  the  constricted  abdom- 
inal tumor. 
16 


226  THE    UMBILICUS   AND    ITS    DISEASES. 

RESULTS. 
Some  of  the  children  were  so  ill  that  no  operation  could  be  undertaken.  Others 
were  operated  upon,  the  abdomen  being  opened,  the  bowel  drawn  back,  and  the 
fistula  closed.  All  these  died.  In  only  one  case  have  we  any  record  of  a  success. 
This  was  in  King's  case,  in  which  no  operation  was  undertaken.  The  bowel  was 
reduced,  and  the  fistula  cauterized.  Finally  it  closed.  The  child  died  later,  prob- 
ably of  pulmonary  tuberculosis. 

FINDINGS  AT  AUTOPSY. 

In  Basevi's  case  Chiari  found  a  fibrinopurulent  exudate  at  the  umbilicus,  and 
a  small  abscess  between  intestinal  loops. 

In  Gesenius's  case,  in  which  no  operation  had  been  performed,  the  omentum  and 
intestine  were  adherent  near  the  umbilicus.  The  intestinal  loops  were  adherent 
and  covered  with  a  reddish  exudate. 

In  Theremin's  Case  1,  no  inflammation  existed  in  the  abdomen,  but  the  pro- 
lapsed bowel  was  markedly  infiltrated. 

The  variability  in  the  location  of  the  omphalomesenteric  duct  was  very  clearly 
brought  out.  In  Lowenstein's  case  it  was  just  above  the  ileocecal  valve;  in 
Gesenius's  case  the  diverticulum  was  1  cm.  long  and  9  inches  above  the  valve;  in 
King's  case,  5  inches  long  and  18  inches  above  the  valve;  in  Blin's  case,  3  to  4  cm. 
long  and  25  cm.  above  the  valve;  in  Ophiils's  case,  35  cm.  above  the  valve,  and  in 
Theremin's  Case  2,  60  cm.  above  the  ileocecal  valve. 


TREATMENT. 

A  careful  study  of  these  cases  clearly  demonstrates  that  when  the  omphalo- 
mesenteric duct  is  patent,  the  wisest  plan  is  at  once  to  make  an  incision  encircling 
the  umbilicus,  draw  out  the  loop  of  bowel,  and  treat  the  fistulous  tract  as  one  would 
an  appendix. 

Newly  born  children  are  only  fair  risks,  yet,  on  the  other  hand,  if  one  waits 
until  prolapsus  has  occurred,  death  is  almost  certain,  as  the  child  has  so  little 
reserve  force. 

In  those  cases  in  which  prolapsus  has  already  occurred  the  same  procedure  may 
be  adopted,  but  in  such  a  case,  after  the  fistula  has  been  closed,  a  loop  of  bowel  just 
above  the  attachment  of  the  diverticulum  should  be  drawn  out  and  opened,  even 
if  there  be  a  remote  possibility  of  prolapsus  occurring  through  this  enterostomy 
wound.  We  are  all  familiar  with  cases  of  strangulated  hernia  in  which  the 
bowel  has  been  obstructed  for  several  days.  In  these,  even  if  the  obstruction  is 
relieved,  death  is  liable  to  follow  from  the  absorption  of  products  of  decomposition 
that  have  been  accumulating  in  the  bowel.  The  same  principle  also  applies  here, 
and  we  must  allow  free  drainage  of  the  bowel  contents. 


CASES  OF  PROLAPSUS  OF  THE  BOWEL  THROUGH  A  PATENT  OMPHALOMESEN- 
TERIC DUCT. 

Three  other  cases  of  prolapsus  of  the  bowel  through  the  vitelline  duct,  those  of 
Gibb,  Guthrie,  and  Peake,  are  recorded  in  Chapter  XL 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     227 


A  Case  of  Prolapsus  of  the  Small  Bowel  Through  the 
Patent  Omphalomesenteric  Duct.  —  Arndt  *  reports  the  case  of 
a  boy  sixteen  days  old.  The  midwife  was  struck  by  the  thickness  of  the  umbilical 
cord  at  the  time  of  labor.  The  father  said  that,  shortly  before  admission,  when  the 
child  vomited,  "pus"  escaped  in  a  stream  from  the  umbilical  region.  The  child  was 
poorly  nourished,  and  at  the  umbilicus  was  a  tumor  the  size  of  a  walnut,  reddish  in 
color,  which  on  manipulation  bled  slightly.  It  was  apparently  covered  over  with 
mucosa.  On  the  right  and  also  on  the  left  upper  portion  of  the  umbilical  projec- 
tion was  an  opening,  into  which  a  sound  could  be  passed  for  a  long  distance.  From 
both  openings  intestinal  contents  escaped  when  pres- 
sure was  made,  or  if  the  child  cried.  Because  of  the 
prolapsus  a  diagnosis  of  patent  omphalomesenteric 
duct  was  made.  Three  days  later  there  was  stool 
by  bowel.  Five  days  after  admission  two  tumors 
could  be  seen — one  was  sausage-shaped,  the  other 
round.  The  former  was  9  cm.  long  (Fig.  137).  It 
doubled  in  length  in  four  days,  became  S-shaped, 
and  both  ends  had  openings.  The  opening  in  the 
upper  end  was  about  the  size  of  a  pea;  the  lower 
opening  was  half  as  large.  Pressure  on  the  child's 
abdomen  increased  the  size  of  the  tumor.  The 
second  tumor  was  situated  in  the  upper  margin 
of  the  umbilical  ring.  It  was  solid  and  as  large  as 
a  hazelnut. 

At  operation  Professor  Runge  found  that  the 
tumor  with  the  two  openings  was  an  inverted  por- 
tion of  the  small  bowel  that  had  passed  through  the 
patent  omphalomesenteric  duct.  When  the  bowel 
was  replaced  in  its  normal  position,  a  hollow  channel 
was  found  passing  from  the  small  bowel  to  the  um- 
bilicus. This  opening  was  about  the  size  of  a  pea. 
The  fistulous  tract  was  removed.  The  child  unfor- 
tunately died  of  peritonitis,  as  the  sutures  did  not 
hold  properly. 

Arndt  says:  "In  this  case  we  have  to  do  with 
prolapsus  of  the  small  bowel  through  the  omphalo- 
mesenteric  duct."      Microscopic   examination   of 

the  solid  umbilical  tumor  showed  that  it  was  an  enteroteratoma  (an  umbilical 
polyp). 

This  case  was  also  reported  by  Ophlils  in  his  monograph. 

Prolapsus  of  the  Small  Intestine  Through  a  Patent 
Omphalomesenteric  Duct.  —  Barth'sf  patient  was  a  child,  nine  days 
old,  who  was  brought  to  the  clinic  on  account  of  a  tumor  at  the  umbilicus.  The 
mother  said  that  this  tumor  was  noted  immediately  after  the  cord  came  away:  The 
cord  itself  did  not  present  anything  unusual,  so  far  as  the  mother  or  midwife  could 


Fig.  137. — Prolapse  op  the  Small 
Bowel  through  an  Open  Om- 
phalomesenteric Duct.  (After 
Arndt.) 

The  sausage-like  mass  ivas  9  cm. 
long.  It  had  doubled  its  length  in  four 
days.  At  both  ends  were  openings. 
These  represented  the  lumen  of  the 
bowel.  The  smaller,  polyp-like  mass, 
seen  in  the  upper  part  of  the  picture, 
was  covered  with  mucosa  and  attached 
to  the  upper  part  of  the  umbilical  ring. 
Histologic  examination  showed  that  it 
was  covered  over  with  intestinal  mu- 
cosa. It  was  a  so-called  adenoma  or 
umbilical  polyp. 


*  Arndt,  C:  Ein  Fall  von  Dunndarmprolaps  durch  den  offen  gebliebenen  Ductus  omphalo- 
entericus.    Arch.  f.  Gyn.,  1896,  lii,  71. 

fBarth,  A.:  Ueber  die  Inversion  des  offenen  Meekel'schen  Divertikels  und  ihre  Complica- 
tion mit  Darmprolaps.     Deutsche  Zeitschr.  f .  Chir.,  1887,  xxvi,  193. 


228  THE    UMBILICUS    AND    ITS    DISEASES. 

tell,  but  through  the  opening  at  the  umbilicus  fecal  matter  had  been  discharging 
for  several  days.  The  bowels  in  the  meantime  had  moved  regularly,  and  the  urina- 
tion was  normal. 

The  child  was  a  well-formed  boy,  and  apart  from  the  umbilical  trouble  was 
apparently  normal.  At  the  umbilicus  was  a  tumor  about  1  cm.  long.  This  was 
of  a  blood-red  color,  and  was  covered  with  injected  mucosa.  On  its  surface  was  an 
opening.  The  tumor  was  1.5  cm.  in  breadth  and  firmly  fixed  at  the  umbilicus.  A 
sound  could  be  passed  into  the  canal  without  difficulty  for  4  cm.  There  was  no 
change  noted  in  the  tumor  when  the  child  cried.  Barth,  having  seen  a  similar 
case  in  Danzig,  came  to  the  conclusion  that  this  was  an  inversion  and  prolapsus 
through  a  patent  Meckel's  diverticulum.  The  small  tumor  was  covered  with 
iodoform  gauze,  a  compression  band  was  applied,  and  the  child  was  brought  to  the 
polyclinic  daily.  For  the  next  few  days  there  was  no  change.  The  child  digested 
well,  and  there  was  very  little  discharge  from  the  umbilicus. 


Fig.  13S. — Prolapsus  of  the  Bowel   Through  a  Patent    Omphalomesenteric  Duct.      (After  Barth's  Fig.   1. 

Redrawn  by  August  Horn.) 

a  is  the  point  at  which  the  bowel  has  prolapsed  and  turned  inside  out  through  the  umbilicus;  c  and  6  are  the  points  at 

which  probes  could  be  introduced  into  the  bowel  lumen. 

Five  days  later  Barth  was  surprised  to  see  that  the  small  tumor  had  been  trans- 
formed into  a  reddish,  sausage-like  tumor,  as  shown  in  Fig.  138.  At  the  umbil- 
ical ring  there  was  now  a  tumor  2.5  cm.  long  and  1.75  cm.  thick.  This  was  con- 
tinuous with  the  sausage-shaped  cylindric  tumor  b-c,  which  was  7  cm.  long  and 
varied  from  1  to  1.5  cm.  in  thickness.  The  entire  tumor,  pedicle,  and  sausage- 
like  mass  were  dark  red  and  covered  over  with  a  slightly  hemorrhagic  mucosa. 
At  b  and  c  the  mucosa  was  continuous  in  the  openings.  The  opening  (6)  led  through 
a  canal  into  the  pedicle  (a),  and  through  the  umbilical  ring  into  the  abdominal 
cavity.  From  the  opening  (6)  fecal  matter  escaped.  The  opening  (c)  led  into  a  canal 
toward  (b),  but  nothing  came  out  of  it.  When  a  sound  was  introduced,  a  wall  could 
be  made  out  between  the  two  openings. 

From  this  description  it  is  seen  that  there  was  a  prolapsus  of  the  inverted 
intestine.  The  child  was  at  once  brought  to  the  hospital.  His  general  condition 
was  good.     There  was  no  pain,  and  the  child's  digestion  was  good.     From  the  open- 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     229 


ing  yellowish  fecal  matter  escaped.  From  the  rectum  nothing  but  mucus  came. 
Dr.  Schmid,  who  saw  the  patient,  thought  of  reducing  the  prolapsus.  Just  as 
soon,  however,  as  this  was  attempted,  the  child  commenced  to  cry  and  more  loops 
of  the  intestine  came  out  at  the  umbilicus.  These  were  seen  to  be  covered  with 
peritoneum.     Other  loops  now  presented  themselves  (Fig.  139). 

Operation. — One  of  the  intestinal  loops  passed  directly  into  the  prolapsed  and 
inverted  bowel.  When  traction  was  made  on 
it,  it  could  be  drawn  back.  The  intestine  was 
supported  only  by  a  small  pedicle.  This  was 
cut  and  the  bowel  was  reduced.  When  reduc- 
tion had  been  effected,  the  intestine  showed  an 
oval  opening  1.5  cm.  long.  One  of  the  assist- 
ants who  was  holding  the  intestine  tore  it,  and 
fecal  matter  came  out.  The  wound  was  at 
once  closed  with  catgut.  The  diverticulum 
was  removed,  and  the  intestine  closed.  The 
child  died  on  the  third  day  after  operation. 
The  autopsy  showed  a  small  abscess  in  the 
upper  portion  of  the  abdominal  wall  and  a  cir- 
cumscribed adhesive  peritonitis.  A  short  con- 
volution of  small  intestine  had  become  at- 
tached to  the  abdominal  wall. 

Prolapsus  of  the  Bowel 
Through  a  Patent  Omphalo- 
mesenteric Duct.*  — -A  well-nour- 
ished child,  twelve  days  old,  came  under  ob- 
servation on  account  of  non-healing  of  the  um- 
bilicus. At  the  umbilicus  was  a  reddish,  moist 
wound.  The  surrounding  tissue  was  normal. 
In  this  case  the  cord  was  thicker  than  usual 
and  had  come  away  on  the  tenth  day.  On 
the  nineteenth  day,  when  the  child  cried,  a 
reddish  cone,  4  cm.  high,  appeared.  This 
showed  no  opening,  and  there  was  stool  by 
the  bowel  daily.  A  few  nights  later  the  child 
suffered  from  discomfort ;  the  tumor  increased 
in  size,  gradually  became  necrotic,  and  the 
child  died.  In  this  case  there  were  prolapsus 
and  inversion  of  the  small  bowel  through  a 
patent  omphalomesenteric  duct  (Fig.  140). 

On  opening  the  abdomen  Dr.  Chiari,  who 
made  the  autopsy,  found  the  small  bowel  attached  to  the  umbilicus  by  a  fibrmopuru- 
lent  exudate,  and  there  was  an  abscess  the  size  of  a  walnut  between  intestinal  loops. 

Prolapsus    of   the   Bowel    Through    a   Patent    Omphalo- 
mesenteric   Duct,  f  —  A  child  six   months  old  was  brought  to  the  Hotel 


Fig.  139. — Prolapsus  of  the  Bowel  through 
a    Patent    Omphalomesenteric    Duct, 
with  Secondary  Complications.     (After 
Barth's  Fig.  3.    Redrawn  by  August  Horn.) 
This  illustration  by  Barth  is  a  diagram- 
matic representation  of  a  hernial  protrusion  that 
may  be  associated  with  the  prolapsed  omphalo- 
mesenteric duct.     &  is  a  proximal  portion  of  the 
bowel  that  has  prolapsed;  c,  the  distal  portion 
of  the  loop.     The  portion  lying  on  the  abdomen 
has  turned  inside  out,  and  is  naturally  covered 
with  mucosa.     A  probe  can  be  readily  intro- 
duced into  the  extra-abdominal  portion,  either 
from  above  or  from  below.     At  x-y  the  bowel 
has  been  markedly  constricted  by  the  abdom- 
inal wall.     The  loop  of  bowel  (d)  has  prolapsed 
to  a   certain  extent    through  a    small    hernial 
opening  above  the  omphalomesenteric  duct. 


*  Basevi,  Settimio:  Jahrb.  f.  Kinderheilk.  u.  physische  Erziehung,  1878,  xii,  275. 

fBlin:  Diverticulum  de  l'intestin  ileum  chez  tin  enfant  de  6  mois;  anus  contre  nature  a 
rombilic,  issue  d'une  anse  intestinale  par  rorifice  ombilical;  etranglement ;  debridement;  mort; 
autopsie.     Mem.  de  la  Soc.  de  biol.,  Paris,  1853,  1.  ser.,  iv,  131. 


230 


THE    UMBILICUS    AND    ITS    DISEASES. 


-    :V 


Dieu  (Jobert's  clinic).  At  the  umbilicus  was  a  cylindric  tumor  lying  transversely 
on  the  abdomen.  This  tumor  was  reddish  brown  and  was  evidently  an  intestinal 
loop.  Below  this  were  two  small  elevations,  the  size  of  peas.  These  were  not  so 
red  as  the  large  tumor;  they  were  resistant  on  pressure  and  adherent  to  the  skin. 

The  mother  said  that  these  two  small  nodules  had  been  noticed  since  the  cord 
came  away,  and  that  below  one  of  the  small  nodules  was  a  minute  opening  from 
which  a  little  fecal  matter  escaped  at  first,  but  later  only  mucus.  Suddenly,  on  the 
day  of  admission,  during  straining,  the  tumor  noted  escaped  from  the  abdomen. 

Reduction  was  impossible.  An  in- 
cision was  made  in  the  ring,  but  the 
child  died  in  two  days. 

At  autopsy  a  diverticulum,  3  to 
/  4  cm.  long  and  of  the  diameter  of  a 

penholder,  was  found.  This  was  25 
cm.  above  the  cecum. 

Inversion  of  the  Small 
Bowel  Through  a  Patent 
Omphalomesenteric 
Duct.*  —  The  patient  was  a 
well-nourished  boy.  The  umbilical 
cord  near  the  abdomen  was  thicker 
than  usual,  and  on  pressure  a  rumb- 
ling, crackling  sound  was  heard.  The 
abdominal  wall  below  the  cord  pre- 
sented a  furrow,  as  if  the  muscles  had 
not  come  together  properly.  The 
cord  was  tied  about  four  inches  from 
the  umbilicus,  and  came  away  on 
the  ninth  day;  the  umbilicus  then 
appeared  to  be  normal.  On  separa- 
tion of  the  folds,  however,  a  small, 
red,  fleshy  wart,  resembling  an  um- 
bilical polyp,  was  seen.  On  the  fol- 
lowing day,  instead  of  the  elevation, 
there  was  an  opening  with  reddish 
walls,  and  two  days  later,  after  the 
child  had  cried  a  good  deal,  a  projection  the  size  of  a  raspberry  was  noted. 
This  had  at  its  summit  an  opening  which  admitted  a  catheter  for  from  six  to 
seven  inches.  From  this  opening  a  little  yellow  fluid  escaped.  The  child  took 
the  breast  well.  The  urine  passed  normally,  and  the  stools  were  regular.  About 
eight  days  later  the  child  was  brought  back,  but  the  condition  was  greatly  changed. 
It  was  very  fretful,  and  cried  continuously.  For  three  days  it  had  had  no  stool. 
At  the  umbilicus  was  a  brownish-red,  glistening  tumor,  which  was  distended  like  a 
sausage.  It  was  three  inches  long,  with  blunt  ends,  and  attached  to  the  umbilicus 
by  a  sort  of  pedicle.  Its  covering  was  undoubtedly  intestinal  mucosa,  and  at  either 
end  was  an  opening  into  which  a  sound  could  be  introduced  for  nearly  an  inch. 

1  i      ii  ins:    Inversion  des  Dlinndarmes  durch  ein  am  Nabcl  off  en  gebliebenes  Divertikel. 
Jonr.  f.  Kinderkrankh.,  1858,  xxx,  56. 


Fig.  140. — Prolapsus  and  Inversion  op  the  Intestine 
through  a  Patent  Omphalomesenteric  Duct.  (After 
Basevi.) 

A  square  piece  of  the  anterior  abdominal  wall,  with  the 
umbilical  ring  in  its  middle,  has  been  removed.  Above  and  to 
the  left  is  the  cecum,  with  the  valve-like  opening  passing  into 
the  small  bowel.  On  the  right  is  the  ileum.  The  bowel  has 
become  inverted  through  the  patent  omphalomesenteric  duct, 
forming  a  somewhat  sausage-like  mass  on  the  surface  of  the 
abdomen.  At  either  end  is  an  intestinal  opening.  The  one 
on  the  left  shows  up  clearly. 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     231 

Around  the  so-called  pedicle  was  a  reddish  ring,  firmly  fixed  and  preventing  the 
introduction  of  a  sound  at  this  point.  There  was  evidently  a  diverticulum  with 
an  inversion  through  it. 

The  child  became  more  restless,  collapsed,  and  died  after  forty-eight  hours. 
At  autopsy,  after  the  omentum  and  intestine  near  the  umbilicus  had  been  loosened 
up,  the  intestine  could  be  pulled  back  and  there  remained  a  diverticulum,  1  cm. 
long,  9  inches  above  the  cecum.  The  intestines  around  it  were  stuck  together  by 
a  reddish  exudate.  In  this  case  there  was  a  patent  omphalomesenteric  duct, 
through  which  the  intestine  had  prolapsed. 

Prolapsus  of  the  Bowel  Through  a  Patent  Omphalo- 
mesenteric Duct.*  —  This  child  was  six  weeks  old.  At  the  umbilicus 
was  an  elongated  cylindric  tumor,  tense  and  reddish  purple  in  color.  It  was  12  cm. 
in  length,  soft  and  elastic.  In  this  case,  when  the  cord  came  away,  a  fecal 
fistula  existed  at  the  umbilicus.  There  was  an  inversion  of  the  intestine  through 
the  fistula,  like  an  inversion  of  the  uterus  or  prolapsus  of  the  bowel  through  the 
anus. 

Operation. — The  bowel  was  reduced  and  the  fistula  closed,  but  the  child  died 
ten  hours  after  operation. 

A  Case  of  Intussusception  Through  a  Patent  Meckel 's 
Diverticulum,  f  — -A  male  infant,  four  weeks  old,  when  seen,  was  almost 
in  collapse.  When  the  cord  had  separated  four  days  after  birth,  the  stools  had 
begun  to  pass  through  the  navel.  During  all  this  time  there  was  a  red  lump  or 
projection  at  the  umbilicus,  and  it  was  through  the  end  of  this  that  the  discharge 
took  place.  Twenty-four  hours  before  admission  a  more  pronounced  protrusion 
was  observed,  and  the  bowels  ceased  to  move  by  the  rectum,  discharging  only  at 
the  umbilicus,  and  not  through  the  apex  of  the  projection,  but  at  its  base,  where  it 
seemed  to  emerge  from  the  original  swelling. 

The  tumor  was  elongated  and  about  the  size  and  length  of  a  little  finger.  It 
depended  from  the  umbilicus,  and  was  inclined  toward  the  left  groin.  It  was 
covered  with  bleeding  mucosa.  It  was  firm,  and  looked  like  an  intussusception. 
Around  its  base  was  a  rolled  collar  or  cuff  of  mucous  membrane,  out  of  which 
emerged  the  protrusion  described.  The  protrusion  was  separated  from  the  collar 
by  a  sulcus,  from  one  part  of  which  yellow  fecal  matter  exuded.  A  probe  inserted 
into  the  apical  opening  passed  in  three  inches  and  met  with  an  obstruction.  A 
probe,  inserted  into  the  basal  groove,  whence  yellow  fecal  contents  were  coming  out, 
passed  without  obstruction  for  several  inches.  There  was  in  this  case  a  prolapsus 
or  intussusception  of  some  of  the  small  bowel  through  a  patent  omphalomesenteric 
duct.     The  child  was  too  ill  for  operation  and  died. 

Prolapse  of  the  Bowel  Through  an  Originally  Par- 
tially Patent  Omphalomesenteric  Duct.}  —  A  boy,  four 
months  old,  had  a  penis-like  tumor  at  the  umbilicus.  This  projection  was  not 
present  at  the  time  of  his  birth.  It  was  covered  over  with  mucosa,  sharply  differ- 
entiated from  the  umbilical  skin,  and  at  its  end  was  a  canal,  into  which  a  sound 

*  Gevaert,  G.:  Inversion  intestinale  a  travers  1'onibilic.  Chirurgie  infantile,  Charon  et  Gev- 
aert,  deuxieme  edition,  Bruxelles,  1895,  251. 

t  Golding-Bird,  C.  H.:   Clin.  Soc.  Trans.,  London,  1896,  xxix,  32. 

t  Hehveg,  Kr.:  Aabent  Diverticulum  ilei,  Invagination,  Prolaps,  Inkarceration.  Hosp. 
Tidende,  1884,  ii,  705. 


232 


THE    UMBILICUS    AND    ITS    DISEASES. 


could  be  introduced  for  one  inch  beyond  the  abdominal  wall;  nothing  escaped  from 
the  opening.     The  stools  were  normal. 

The  tumor,  which  was  hard  at  its  base,  was  tied  off  with  a  silk  ligature.  It 
became  necrotic  in  four  days.  As  a  result  of  violent  coughing,  prolapse  of  an 
S-shaped  piece  of  intestine  with  a  dark-red  mucous  lining  took  place  (Fig.  141). 
It  was  attached  to  the  umbilicus  by  a  short  pedicle.     The  portion  of  intestine 

lying  on  the  abdomen  was  eight  to  nine  inches 
long,  and  as  thick  as  the  small  intestine  of  an  adult. 
At  both  free  ends  was  a  canal.  After  loosening  up 
the  tumor  at  the  umbilicus  the  operator  found  that 
two  pieces  of  small  bowel  had  passed  out  of  the  um- 
bilical ring  into  the  horns  of  the  prolapsus.  After 
making  traction  on  the  intestine  he  was  able  to  draw 
back  both  horns,  but  there  remained  an  opening  in 
the  bowel  the  size  of  a  mark.  This  communicated 
with  the  umbilicus  and  was  the  patent  omphalo- 
mesenteric duct.  The  bowel  was  closed.  The  child 
died  a  few  hours  later. 

At  autopsy  a  beginning  peritonitis  was  found 
around  the  umbilical  region.  The  omphalomesen- 
teric duct  was  18  inches  above  the  ileocecal  valve. 

Prolapse  of  the  Bowel  Through 
a  Patent  Omphalomesenteric  Duct. — 
Holmes*  described  a  specimen  that  had  been  sent 
to  him  by  Dr.  H.  Whiteman.  It  was  from  a  male 
infant  which  had  been  born  prematurely  with  a  bifur- 
cated cord.  The  bifurcation  began  three  inches  from 
the  abdomen.  The  cord  was  tied  below  it.  At  the 
end  of  two  weeks  feces  were  coming  from  the  umbili- 
cus, and  the  surrounding  tissues  were  inflamed.  The 
intestine  rolled  out,  and,  when  Holmes  saw  the  pa- 
tient, a  loop  was  hanging  out  of  the  abdomen  and 
feces  were  coming  from  it.  There  was  evidently  some 
defect  in  the  closure  of  the  umbilical  opening,  prob- 
ably due  to  a  fissured  cord,  and  Holmes  thought  that 
the  nurse  had  probably  retied  the  cord  after  Dr. 
Whiteman  had  tied  it  well  away  from  the  abdomen, 
and  that  she  had  tied  off  the  end  of  the  bowel. 
Attempts  were  made  to  push  the  bowel  back  in 
order  to  use  Dupuytren's  clamp  method.  The 
child  did  well  for  several  days,  but  the  bowel  came  out  again  and  death  oc- 
curred. In  this  case,  until  prolapse  of  the  bowel  took  place,  the  feces  passed 
by  the  rectum. 

[The  history  of  the  case  leaves  no  doubt  that  a  patent  omphalomesenteric  duct 
existed  and  that  the  nurse  was  in  no  way  responsible  for  the  injury.] 


Fig.  141. — Prolapsus  of  the  Bowel 

THROUGH  THE  PaTEXT  OMPHALO- 
MESENTERIC Duct.  (After  Hel- 
weg.) 

A  boy,  four  months  old,  had  a 
definite  projection  at  the  umbilicus. 
This  was  covered  over  with  mucosa 
and  was  sharply  differentiated  from 
the  abdominal  skin.  A  sound  could 
be  passed  for  a  certain  distance  into 
the  abdomen.  The  tumor  was  tied 
off  at  its  base  with  a  silk  ligature.  It 
became  necrotic  in  four  days. 

As  a  result  of  violent  coughing  an 
S-shaped  piece  of  intestine  with  a 
dark-red  mucosa  escaped  through  the 
umbilical  opening.  It  was  attached 
to  the  umbilicus  by  a  short  pedicle. 
At  each  end  was  a  canal.  After  the 
tumor  had  been  loosened  at  the  um- 
bilicus, it  was  found  that  two  pieces 
of  small  bowel  had  passed  out  of 
the  umbilical  ring  and  terminated  in 
each  horn  of  the  prolapsus.  In  other 
words,  the  bowel  had  turned  inside 
out  through  the  patent  omphalomes- 
enteric duct.  The  child  died  a  few 
hours  after  operation. 


182. 


Holmes,  T.:  Surgical  Treatment  of  the  Diseases  of  Infancy  and  Childhood,  London,  1868, 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     233 

Prolapsus  of  the  Small  Bowel  Through  a  Patent 
Omphalomesenteric  Duct.*  —  A  boy,  twelve  days  old,  was  supposed 
to  have  a  persistence  of  Meckel's  diverticulum.  The  midwife  had  tied  off  the  cord 
well  away  from  the  body.  When  Hue  saw  the  child,  there  was  a  sausage-like  pro- 
jection, about  the  size  of  an  adult's  thumb,  and  about  10  cm.  long,  lying  on  the 
abdomen.  It  was  evidently  covered  with  mucosa,  and  bore  some  resemblance  to 
a  prolapsed  rectum  in  a  child.  It  was  deep  red  in  color,  livid,  and  had  two  ori- 
fices on  its  surface.  The  first  was  situated  near  the  middle  of  the  tumor,  and  from 
it  gas  and  partly  digested  intestinal  contents  escaped.  The  second  was  situated 
at  the  end  of  the  tumor,  and  from  this  neither  gas  nor  feces  came. 

For  the  first  three  days  stools  were  passed  by  the  rectum.  After  that  nothing 
escaped  by  the  normal  route.  An  enema  of  water  and  milk  returned  without 
escaping  through  either  of  the  abdominal  openings. 

At  autopsy  it  looked  as  if  there  had  been  a  prolapse  of  Meckel's  diverticulum. 
There  was  a  persistence  of  the  left  omphalomesenteric  artery.  Deve,  in  the 
discussion  of  Hue's  case,  reported  a  case  in  which  this  also  had  persisted. 

Prolapsus  of  the  Bowel  Through  a  Patent  Omphalo- 
mesenteric Duct.- — ■  Hiittenbrennerf  saw  a  child  who,  as  a  result  of  an 
attack  of  whooping-cough  in  the  fifth  month,  had  a  prolapse  of  nine  inches  of  bowel 
from  the  umbilicus.  .The  prolapsed  portion  lay  as  a  transverse  tumor  on  the 
abdomen,  and  on  each  side  had  an  opening.  The  condition  was  diagnosed  as  an 
invagination  of  the  bowel  through  a  patent  omphalomesenteric  duct.  After  re- 
moval of  the  prolapsus  death  followed  as  result  of  pneumonia. 

A  Patent  Omphalomesenteric  Duct  with  Prolapse 
of  the  Intestine  Through  i  t  .  t  —  A  male  child  was  seen  on  the  eighth 
day.  Occupying  the  umbilicus  was  a  fungoid  growth  supposed  to  have  been  caused 
by  the  nurse  pulling  on  the  cord  and  cutting  it  off  too  short.  The  fungus  was 
removed  by  means  of  caustics.  When  it  came  away,  feces  escaped.  The  child 
was  greatly  emaciated;  it  developed  a  bronchitis,  and  a  piece  of  bowel  four 
inches  long  protruded  through  the  umbilicus.  During  a  fit  of  coughing  feces 
were  seen  escaping  from  its  open  extremity.  At  the  same  time  feces  passed  by  the 
bowel.  The  wound  was  closed  by  cicatrization  in  about  a  year,  but  the  child  died 
a  little  later  on,  probably  of  tuberculosis. 

Autopsy. — The  diverticulum,  which  was  five  inches  long,  was  found  18  inches 
above  the  cecum,  and  extended  from  the  convexity  of  the  ileum  to  the  umbilicus, 
to  which  it  was  firmly  attached.  The  umbilicus  itself  appeared  to  be  fairly  normal. 
There  was  in  its  center  an  area  of  granulation  the  size  of  a  pea. 

A  Patent  Omphalomesenteric  Duct  with  Prolapse  of 
the  Bowel  Through  it.§  — ■  The  patient  was  a  boy  who  had  at  the  umbil- 
icus a  reddish  tumor  the  size  of  a  strawberry.  This  was  thought  to  be  telangiectatic, 
and  was  accordingly  tied  off  and  removed.  Kolbing  saw  the  child  when  nineteen 
weeks  old.  Projecting  through  the  umbilicus  was  a  piece  of  red  and  distended 
intestine.     The  child  was  operated  on  at  once,  but  died  in  thirteen  hours.     The 

*  Hue,  Francois:  Prolapsus  ombilical  diverticulaire.     La  Normandie  med.,  1906,  xxi,  162. 

t  Huttenbrenner,  A.:  Allgem.  Wien.  med.  Zeitung,  1878,  Nr.  23,  225,  235. 

t  King,  T.  W.:   Guy's  Hospital  Reports,  1843,  2.  ser.,  i,  467. 

§  Kolbing,  A. :  Beschreibung  einer  auf  dem  Nabel  eines  neugebornen  Kindes  befindlichen 
rothlichen  Geschwulst,  besonders  wegen  ihrer  Folgen  merkwiirdig.  Neue  Zeitschr.  f.  Geburtsk., 
1843,  xiv,  443. 


234  THE    UMBILICUS    AND    ITS    DISEASES. 

small  intestine  had  grown  to  the  lower  end  of  the  umbilical  opening,  and  through 
the  opening  the  intestine  had  inverted. 

[Tillmanns  said  the  ease  was  one  of  prolapsus  in  the  usual  sense,  namely, 
through  inversion  of  the  bowel.] 

Prolapsus  of  the  Bowel  Through  a  Patent  Omphalo- 
mesenteric Duct.*  —  A  personal  communication  from  Karewski.  The 
patient  was  a  three-months-old  boy  who  was  in  good  health.  On  the  fourteenth 
day  there  was  "inflammation"  of  the  umbilicus,  and  a  spontaneous  opening 
appeared  from  which  a  thin  yellow  fluid  escaped.  Dermatitis  developed,  and  on 
the  surface  of  the  prominence  of  the  umbilicus  a  pea-sized  opening  was  seen.  This 
was  lined  with  a  very  red  mucosa,  and  from  it  there  escaped  a  feces-like  discharge. 
Operation  was  refused.  In  consequence  of  ulceration  the  opening  soon  became  the 
size  of  a  50-pfennig  piece,  and  the  child  grew  very  weak.  In  three  weeks  the  open- 
ing had  increased  to  the  size  of  a  plum.  The  child  cried  a  good  deal  and  had  stop- 
page of  the  bowels  for  several  days.  Strong  pressure  was  applied  to  the  umbilicus. 
Finally  a  prolapsus  took  place  at  the  umbilicus,  and  a  small  piece  of  bowel,  5  cm. 
long,  came  down  through  the  open  omphalomesenteric  duct.  An  abdominal 
incision  was  made,  and  the  prolapsus  was  easily  reduced.  The  open  omphalo- 
mesenteric duct  was  situated  just  above  the  ileocecal  valve.  It  was  tied  off  and 
removed.     The  child,  however,  died  twenty-four  hours  later. 

At  the  present  time  in  such  a  case  an  immediate  laparotomy  would  be  indicated; 
the  diverticulum  should  be  tied  off,  the  umbilicus"  removed,  and  probably  a 
temporary  enterostomy  made. 

Prolapsus  of  the  Bowel  Through  an  Open  Omphalo- 
mesenteric Duct.  —  Ophuls  |  gives  the  autopsy  report  on  a  three-weeks- 
old  boy.  The  clinical  diagnosis  was  peritonitis  following  a  laparotomy.  This 
operation  had  been  performed  on  account  of  prolapsus  of  the  bowel  through  an 
open  Meckel's  diverticulum,  10  to  15  cm.  of  the  bowel  having  prolapsed.  In  this 
case  the  bowel  had  been  reduced  and  the  diverticulum  removed.  In  the  vicinity 
of  the  umbilical  fistula  was  a  small  tumor  the  size  of  a  hazelnut.  It  was  roundish 
and  firm  in  consistence,  and  covered  over  with  mucosa.  It  was  entirely  inde- 
pendent of  the  bowel. 

Autopsy  showed  that  the  intestinal  suture  had  not  held,  and  that  fecal  matter 
had  escaped  into  the  general  abdominal  cavity.  The  closure  in  the  bowel  was 
found  to  be  35  cm.  above  the  ileocecal  valve,  and  on  the  side  opposite  the  mesentery. 

Prolapsus  of  the  Bowel  Through  a  Patent  Omphalo- 
mesenteric Duct.  |  —  A  recently  born  child  showed  moisture  at  the  um- 
bilicus, which  was  found  to  be  unusually  prominent  and  firm.  There  was  a  groove 
in  the  middle  where  cicatrization  had  not  occurred.  Here  there  was  still  moisture, 
and  yellow  fluid  and  gas-bubbles  escaped.  Siebold  thought  the  condition  was  due 
to  lack  of  closure  of  the  vitelline  duct.  At  the  end  of  the  third  week  a  small,  black, 
gangrenous  area  was  noted.     When  the  child  cried,  the  small  bowel  was  forced  out 

*  Lowenstein,  L.:  Der  Darmprolaps  bei  Persistenz  des  Ductus  omphalo-mesentericus  mit 
Mittheilung  eines  operativ  geheilten  Falles.  Langenbeck's  Arch.  f.  klin.  Chir.,  1894-95,  xlix, 
541. 

t  Ophuls,  W.:  Beitrage  zur  Kenntnis  der  Divert ikel-Bildungen  am  Darmkanal.  Inaug. 
Diss.,  Gottingen,  189.".,  36. 

i  Siebold,  quoted  by  G.  Schroder:  Uber  die  Divertikel-Bildungen  am  Darm-Kanale.  Inaug. 
Diss.  (Erlangen),  Augsburg,  1854. 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     235 

from  right  to  left  from  the  gangrenous  opening,  forming  two  horns,  like  sausage- 
skins  filled  with  air;  and  when  the  child  cried,  both  ends  lengthened.  A  small 
opening  was  made  at  the  umbilicus,  and  the  intestine  reduced.  The  child  died  in  a 
few  hours.  Autopsy  revealed  a  diverticulum  three-quarters  of  an  inch  in  length, 
which  had  opened  at  the  umbilicus. 

Prolapsus  of  the  Bowel  Through  a  Patent  Omphalo- 
mesenteric Duct.*  —  The  patient  was  a  well-developed  boy.  At  birth 
it  was  noted  that  the  umbilical  cord  was  remarkably  large  at  its  base.  It  came 
away  on  the  eleventh  day.  In  the  center  of  the  cutaneous  umbilical  ring  was  a 
reddijsh  tumor,  conic  in  form,  and  resembling  a  fungus  of  the  umbilicus.  There 
were  small  ulcers  on  the  surface  of  the  tumor,  and  on  the  twenty-third  day  super- 
ficial hemorrhage  occurred.  The  small  intestine  prolapsed  through  a  fistula  in  the 
form  of  two  horns,  each  5  to  6  cm.  in  length,  which  were  curved,  forming  a  semi- 
circle. They  were  covered  over  with  mucous  membrane.  Attempts  at  reduction 
were  made,  without  result.     Two  days  later  the  child  died. 

The  autopsy  showed  a  true  diverticulum  of  the  small  intestine  adherent  to  the 
umbilical  ring,  and  a  prolapse  of  the  bowel  through  it.  There  was  no  trace  of 
inflammation  of  the  peritoneum  or  of  the  intestine  that  had  remained  in  the 
abdomen,  but  there  was  marked  infiltration  of  the  prolapsed  portion  of  the 
bowel. 

Prolapsus  of  the  Bowel  Through  a  Patent  Omphalo- 
mesenteric Duct. f  —  A  boy  was  born  on  February  26,  1884,  and  admitted 
to  the  hospital  on  February  29th.  The  cord  came  away  on  the  eighth  day,  and  at 
the  umbilical  orifice  was  a  small  tumor  which  resembled  a  fungus.  This  was  conic, 
red,  and  measured  1.5  cm.  x  1  cm.  At  its  base  there  was  no  vestige  of  an  opening. 
By  March  16th,  twelve  days  after  the  cord  had  come  away,  the  fungus  had  receded 
somewhat  and  was  not  over  5  mm.  high,  but  there  was  a  small  ulcer  in  its  center, 
from  which  a  few  drops  of  clear  blood  escaped.  On  the  following  day,  while  the 
bandage  was  being  changed,  the  child  cried,  and  there  emerged  from  the  summit  of 
the  tumor  a  mass  resembling  granulation.  This  was  covered  with  mucosa  and  had 
a  small  central  opening.  On  March  21st  there  was  an  intestinal  prolapsus  for  a 
length  of  10  cm.  The  mucosa  was  red  and  a  yellow  mucus  escaped  from  the  central 
opening.  Gas  and  fecal  matter  also  came  away  when  the  child  cried.  The  general 
condition  was  not  satisfactory,  and  it  was  impossible  to  reduce  the  prolapsus. 
Later  the  prolapsus  receded  in  part,  leaving  a  prominence  measuring  only  5  mm. 
The  child  died  of  gastro-intestinal  catarrh  on  April  29th. 

At  autopsy  there  were  signs  of  an  acute  enteritis  with  engorgement.  The  mesen- 
teric glands  were  tumefied,  reddish,  and  softened.  The  intestinal  prolapsus  had 
been  reduced  completely.  The  diverticulum  was  60  cm.  above  the  cecum.  It 
was  inserted  into  the  umbilical  ring.  The  mucosa  reached  the  umbilical  opening. 
There  was  atelectasis  in  the  posterior  part  of  both  lungs. 

Prolapse  of  the  Bowel  Through  a  Patent  Omphalo- 
mesenteric Duct. J  —  The  patient  was  a  well-formed  boy.  After  the 
dropping  off  of  the  umbilical  cord  a  small,  rather  prominent,  tumor,  resembling  a 
wild  strawberry,  was  noted  at  the  umbilicus.     The  physician  raised  it  and  tied  it 

*  Theremin,  E.:  Sur  les  fistules  entero-ombilicales  diverticulaires.  Rev.  mens.  d.  mal.  de 
l'enfance,  1885,  558. 

f  Theremin:  Loc.  cit.,  Case  2.  J  Violbing:    (Quoted  by  Bureau,  op.  cit.). 


236  THE    LTMBILICUS    AND    ITS    DISEASES. 

off  at  its  base.  When  the  child  was  nineteen  weeks  old  there  occurred  a  prolapsus 
of  the  intestine  1  %  feet  in  length  through  the  umbilicus.  It  came  out  as  two  cornua ; 
these  were  covered  with  mucosa.  Death  soon  followed.  At  autopsy  a  diverticu- 
lum was  found  opening  into  the  bowel. 

Prolapse  of  Intestine  Through  a  Patent  Omphalo- 
mesenteric Duct.*  —  J.  G.,  five  months  old,  was  admitted  to  the 
hospital  on  March  23,  1873.  The  umbilicus  had  been  open  since  birth,  and 
occasionally  mucus  had  escaped,  but  no  feces.  During  a  severe  coughing  spell  the 
day  before  his  admission  a  bright-red,  two-horned  tumor  had  appeared  at  the 
umbilicus.  The  left  horn  was  4  cm.  long,  the  right  11  cm.  long,  with  several  furrows 
on  its  concave  side.  At  the  end  of  each  horn  was  an  opening  which  admitted  the 
tip  of  a  finger.  No  feces  escaped  from  these  openings.  The  prolapsed  tumor  was 
constricted  at  the  umbilicus. 

The  tumor  was  dark  red,  and  undoubtedly  covered  with  mucosa.  The  surface 
was  covered  with  mucus  and  bled  readily. 

The  abdomen  was  markedly  distended;  the  child  was  very  pale  and  breathed 
with  difficulty.     There  was  no  vomiting. 

The  growth  was  cut  off,  a  short  stump  and  two  lumina  being  left.  The  child 
died  thirty  hours  later. 

*  Weinlechner:  Vorfall  des  Dtinndarms  durch  den  off  en  gebliebenen  Ductus  omphalo- 
mesaraicus.    Jahr.  f .  Kinderheilk.  u.  physische  Erziehung,  N.  F.,  1874-75,  viii,  55. 


LITERATURE  CONSULTED  ON  PROLAPSUS  OF  THE  BOWEL  THROUGH  A  PATENT 

OMPHALOMESENTERIC  DUCT. 
Amdt,  C:    Ein  Fall  von  Dunndarmprolaps   durch  den    off  en    gebliebenen  Ductus  omphalo- 

entericus.    Arch.  f.  Gyn.,  1896,  lii,  71. 
Barth,  A.:    Ueber  die  Inversion  des  offenen  Meckel'schen  Divertikels  und  ihre  Complication 

mit  Darmprolaps.    Deutsche  Zeitschr.  f .  Chir.,  1887,  xxvi,  193. 
Basevi,  Settimio:  Jahrb.  f.  Kinderheilk.  u.  physische  Erziehung,  1878,  xii,  275. 
Blin:  Diverticulum  de  l'intestin  ileum  chez  un  enfant  de  6  mois;  anus  contre  nature  a  l'ombilic, 

issue    d'une   anse   intestinale    par   l'orifice    ombilical;    etranglement;    debridement;    mort; 

autopsie.     Mem.  de  la  Soc.  de  biol.,  Paris,  1853,  1.  ser.,  iv,  131. 
Bureau,  J. :  Prolapsus  ombilical  du  diverticule  de  Meckel.     These  de  Paris,  1898,  No.  257. 
Gesenius:  Inversion  des  Diinndarmes  durch  ein  am  Nabel  off  en  gebliebenes  Divertikel.    Jour.  f. 

Kinderkrankh.,  1858,  xxx,  56. 
Gevaert,  G.:   Inversion  intestinale  a  travers  l'ombilic.  Chirurgie  infantile.    Charon  et  Gevaert, 

deuxieme  edition,  Bruxelles,  1895,  251. 
Golding-Bird,  C.  H.:  A  Case  of  Intussusception  through  a  Patent  Meckel's  Diverticulum.    Clin. 

Soc.  Trans.,  London,  1896,  xxix,  32. 
Helweg:     Aabent   Diverticulum  ilei.     Invagination,    Prolaps,    Inkarceration.     Hosp.    Tidende, 

1884,  ii,  705. 
Holmes,  T. :  Surgical  Treatment  of  the  Diseases  of  Infancy  and  Childhood,  London,  1868,  182. 
Hue,  P>ancois:  Prolapsus  ombilical  diverticulaire.     La  Normandie  med.,  1903,  xxi,  162. 
Huttenbrenner,  A.:  Allgem.  Wiener  med.  Zeitung,  1878,  xxiii,  225,  235. 
King,  T.  W.:  Fseculent  Discharge  at  the  Umbilicus  From  Communication  with  the  Diverticulum 

Ilei.     Guy's  Hospital  Reports,  1843,  2.  ser.,  i,  467. 
Kolbing,  A. :   Beschreibung  einer  auf  dem  Nabel  eines  neugebornen  Kindes  befmdlichen  rothlichen 

( reschwulst,  besonders  wegen  ihrer  Folgen  merkwurdig.     Neue  Zeitschr.  f.  Geburtsk.,  1843, 

xiv,  443. 
Lowenstein:   Der  Darmprolaps  bei  Persistenz  des  Ductus  omphalo-mesentericus,  mit  Mittheilung 

cine-  open-it  iv  jrr-lieilten  Falles.     Langenbeck's  Arch.  f.  klin.  Chir.,  1894-95,  xlix,  541. 


PROLAPSUS  OF  BOWEL  THROUGH  PATENT  OMPHALOMESENTERIC  DUCT.     237 

Ophuls,  W.:    Beitrage  zur  Kenntnis  der  Divertikelbildungen   am    Darmkanal.     Inaug.  Diss., 

Gottingen,  1895,  S.  36. 
Siebold :   (Quoted  by  G.  Schroder,  tJber  die  Divertikel-Bildungen  am  Darm-Kanale.   Inaug.  Diss. 

(Erlangen),  Augsburg,  1854.) 
Theremin:    Sur  les  fistules  entero-ombilicales  diverticulaircs.     Rev.  mens.  mal.  de  l'enfance, 

1885,  558. 
Violbing:   (Described  in  Bureau's  article,  Op.  cit.) 
Weinlechner:   Vorfall  des  Dtinndarms  durch  den  off  en  gebliebenen  Ductus  omphalo-mesaraicus. 

Jahrb.  f .  Kinderheilk.  u.  physische  Erziehung,  N.  F.,  1874-75,  viii,  55. 


CHAPTER  XIII. 

CYSTS  IN  THE  ABDOMINAL  WALL  DUE  TO  REMNANTS  OF  THE 
OMPHALOMESENTERIC   DUCT. 

Historic  sketch. 

Cysts  developing  between  the  peritoneum  and  muscles. 

Subcutaneous  cysts. 

Report  of  cases. 

Wtss  and  Colmers  have  each  reported  a  case  in  which  a  small  cyst  was  found 
lying  between  the  peritoneum  and  the  abdominal  muscles.  Zumwinkel  observed 
a  cyst  lying  external  to  the  abdominal  muscle. 

Wyss's  cyst  was  the  size  of  a  bean;  Colmers'  was  as  large  as  a  hen's  egg  and 
divided  into  two  cavities;  Zumwinkel's  was  the  size  of  a  cherry-stone. 

As  will  be  noted  from  the  histories,  in  each  case  the  inner  surface  of  the  cyst  at 
some  point  was  lined  with  cylindric  epithelium,  and  in  Colmers'  and  Zumwinkel's 


Fig.  142. — A  Small  Cyst  of  the  Umbilicus  Due  to  a 
Remnant  of  the  Omphalomesenteric  Duct. 
This  is  a  schematic  representation  of  a  small  cystic 
remnant  of  the  omphalomesenteric  duct  lying  just  ex- 
ternal to  the  peritoneum  and  communicating  with  the 
umbilicus.  Passing  from  it  to  the  bowel  is  a  fibrous 
remnant  of  an  omphalomesenteric  vessel. 


Fig.  143. — Small  Cyst  of  the  Abdominal  Wall  due 
to  a  Remnant  of  the  Omphalomesenteric  Duct. 
In  rare  instances  a  small  cyst  may  be  found  in  the 
abdominal  wall  in  the  umbilical  region.  This  cyst  is 
lined  with  a  mucosa  resembling  to  a  more  or  less  marked 
degree  intestinal  mucosa.  This  is  a  schematic  repre- 
sentation of  such  a  cyst. 


cases  Lieberkiihn's  glands  were  demonstrable.  In  these  two  cases  the  walls  of  the 
cyst  also  contained  non-striped  muscle. 

In  Zumwinkel's  case  the  cyst  was  connected  with  the  umbilicus  by  a  fine  open- 
ing, and  in  Colmers'  case  the  patent  omphalomesenteric  vessels  were  still  present 
in  the  cord  passing  from  the  cyst  to  the  umbilicus.  These  cysts,  without  a  doubt, 
were  due  to  remnants  of  the  omphalomesenteric  duct. 

In  Figs.  142  and  143  we  have  schematic  representations  of  cysts  developing  just 
externally  to  the  peritoneum  and  in  the  umbilicus  itself. 

A  Small  Cyst  Between  the  Peritoneum  and  Muscle, 
Probably  Remains  of  the  Omphalomesenteric  Duct.*  — 
At  autopsy,  about  an  inch  above  the  umbilicus  and  a  little  to  the  side  of  the  linea 

*  Wyss,  Hans  v.:    Zur  Kenntnis  der  heterologen  Flimmercysten.     Virchows  Arch.,  1870, 
li,  143. 

238 


CYSTS    IN   THE    ABDOMINAL   WALL.  239 

alba,  Wyss  found  a  cyst,  the  size  of  a  bean,  between  the  muscle  and  peritoneum. 
This  contained  turbid  and  tenacious  mucus,  which  was  grayish  yellow  in  color. 
The  cyst  was  lined  with  cylindric,  ciliated  epithelium,  an  epithelium  that  had 
undergone  colloid  change.  Wyss  thought  the  cyst  might  represent  embryonic 
remains.     The  findings  strongly  suggest  remains  of  the  omphalomesenteric  duct. 

An  Enterocystoma  Developing  Between  the  Peri- 
toneum and  the  Recti  Muscles.  —  Colmers*  considers  enterocystoma 
of  the  abdominal  wall,  but  before  giving  his  own  case,  mentions  those  reported  by 
v.  Wyss,  Roser,  and  Schaad. 

Colmers,  in  1903,  saw  Frau  K.  0.,  aged  forty-six.  She  had  always  been  healthy 
and  was  the  mother  of  12  children.  Her  illness  commenced  in  the  summer  of  1903. 
In  August  she  noticed  that  every  movement  of  the  body  excited  pain  in  the  abdomen. 
No  further  trouble  was  noted  until  October,  when  there  were  digestive  disturb- 
ances. When  admitted  to  the  hospital  (November  17th)  the  woman  was  fairly 
well  nourished,  but  the  skin  was  pale.  The  abdomen  was  firm.  On  careful  palpa- 
tion an  indefinite  resistance  could  be  felt  around  the  umbilicus.  The  mass  was 
the  size  of  an  egg,  firm  in  consistence,  and  very  movable. 

Operation. — When  the  abdomen  was  opened,  a  fluctuating  tumor,  the  size  of 
a  small  hen's  egg,  was  found  in  the  umbilical  region.  It  was  attached  to  the  abdom- 
inal peritoneum  and  partly  nipped  off  from  a  small  one  about  the  size  of  a  hazel-nut. 
This  was  also  in  the  abdominal  wall.  Passing  from  the  tumor  to  the  umbilicus 
was  a  short,  thick  cord.  The  tumor  was  dissected  out  of  the  abdominal  wall  with- 
out difficulty.  The  stomach,  intestine,  and  mesentery,  as  well  as  the  uterus  and 
adnexa,  were  normal.  A  somewhat  enlarged  gland  from  the  greater  curvature  of 
the  stomach  was  removed.  This,  on  histologic  examination,  showed  a  simple 
hyperplasia.  The  extirpated  tumor  lay  between  the  peritoneum  and  the  sheath 
of  the  rectus.     With  the  latter  it  had  formed  a  broad  adhesion. 

The  tumor  contained  a  thick  yellowish  fluid,  which  had  colorless  masses, 
resembling  mucus,  scattered  through  it.  The  fluid  contained  numerous  fat-drop- 
lets, many  cholesterin  crystals  and  fatty  acid  needles,  as  well  as  cells  closely  re- 
sembling fatty  epithelium.  The  walls  of  the  large  cyst  had  on  the  inner  surface 
numerous  calcareous  particles.  These  were  attached  to  the  wall  or  lay  free  in  the 
cyst  cavity.  The  wall  of  the  portion  of  the  cyst  lying  beneath  the  peritoneum  was 
not  over  0.2  mm.  in  thickness,  and  in  places  only  0.1  mm.  thick.  Near  it  were  little 
bays  or  depressions  running  out  in  various  directions.  Here  the  walls  reached  a 
thickness  of  0.5  mm. 

These  cysts  communicated  with  each  other  by  a  small  opening  through  which 
a  sound  could  pass.  The  cord  extending  from  the  small  cyst  to  the  umbilicus 
appeared  to  be  solid.  The  free  walls  of  the  cyst,  that  is,  the  portion  lying  beneath 
the  peritoneum,  contained  connective  tissue,  in  the  inner  layers  of  which  calcareous 
deposits  were  found.     No  epithelial  lining  could  be  detected. 

The  small  cyst  was  similar  to  the  larger  one.  Here,  however,  the  calcareous 
deposit  was  not  marked.  At  one  point  at  the  base  of  the  cyst  were  two  small 
bays.  These  communicated  with  the  main  cyst  by  a  small  opening.  The  two 
small  cysts,  as  indicated  in  Fig.  144,  a,  b,  were  lined  with  a  beautiful,  very  high 
cylindric    epithelium.     This    contained    definite    Lieberkuhn's    glands,   although 

*  Colmers,  F. :  Die  Enterokystome  und  ihre  chirurgische  Bedeutung.  Arch.  f.  klin.  Chir., 
1906,  lxxix,  132. 


240  THE    UMBILICUS    AND    ITS    DISEASES. 

these  were  low  and  often  irregular.  Sometimes  papillae  were  found  projecting  into 
the  lumen  of  the  cyst.  This  glandular  layer  covered  a  definite  muscularis  mucosae 
in  which  bands  of  smooth  muscle-fiber  were  seen.  The  glands  were  not  regular. 
but  in  some  places  they  were  arranged  at  right  angles  to  one  another.  At  a  few 
points  there  were  evidences  of  Auerbach's  plexus. 

The  cord  passing  from  the  small  cyst  contained  the  omphalomesenteric  vessels. 
Two  of  them  had  remained  open  and  were  surrounded  by  smooth  muscle-fibers. 
The  diagnosis  was  not  difficult.  The  cysts  had  developed  from  remains  of  the 
omphalomesenteric  duct. 

A  Subcutaneous  Cyst  Originating  From  the  Omphalo- 
mesenteric Duct.*- — ■  The  patient  was  a  child  seven  years  old.  Since 
birth  there  had  been  a  small  opening  at  the  umbilicus,  which  secreted  a  slimy  fluid. 
In  the  right  abdominal  wall  in  the  umbilical  region  was  a  roundish,  ulcerated,  hard 


'-^i--'  ^A 


Fig.  144. — A  Small  Intestinal  Ctst  Lying  Between  the  Peritoneum  and  the  Recti.     (After  Colmers.) 
This  picture  represents  one  of  the  small  bays  running  off  from  the  large  cyst,  and  communicating  with  it  by  a  fine 
opening.     At  a  we  have  Lieberkuhn's  glands,  some  with  well-developed  papillary  folds.     The  cyst  space  (6)  in  some 
places  is  lined  with  mucosa.     At  other  places  the  epithelium  is  somewhat  flattened  or  has  disappeared  completely. 
Surrounding  the  glands  is  non-striped  muscle  cut  longitudinally  and  transversely. 

nodule,  1.25  cm.  in  diameter.  In  the  middle  was  a  fine  opening  through  which  a 
sound  could  be  passed  1  cm.  into  a  cavity. 

At  operation  a  cyst  the  size  of  a  cherry-stone  was  found.  This  was  round, 
bluish  in  color,  and  easily  loosened  by  blunt  dissection  from  the  underlying 
tissue. 

The  inner  surface  of  the  cyst  was  lined  with  cylindric  epithelium,  intestinal 
folds,  and  Lieberkuhn's  glands.  Outside  of  this  was  a  muscular  zone.  In  some 
places  this  was  cut  lengthwise;  at  others,  transversely.  It  consisted  of  two  layers. 
The  mucosa  was  not  normal.  The  folds  or  papillae  were  high  and  broad,  and  some- 
times had  several  projections,  suggesting  a  papilloma.  The  glands  were  more 
abundant.  The  muscle  was  especially  thick.  At  only  one  point  did  the  sac  show 
normal  mucosa. 

The  squamous  epithelium  in  the  vicinity  of  the  cyst  was  increased  in  thickness- 
In  some  places  it  was  ten  times  as  thick  as  normal.  The  papillae  of  the  skin  were 
also  much  lengthened. 

*  Zumwinkel:  Subcutane  Dottergangscyste  des  Xabels.  Langenbeek's  Arch.  f.  klin.  Chir., 
1890,  xl,  838. 


CYSTS    IN    THE    ABDOMINAL   WALL.  241 

Zumwinkel  says  that  in  Roser's  case  the  cyst  lay  behind  the  navel,  just  extra- 
peritoneally,  whereas  his  cyst  lay  in  front  of  the  closed  navel. 

In  Zumwinkel's  case  the  skin  surrounding  the  umbilicus  was  greatly  thickened, 
the  squamous  epithelium  in  places  being  fully  ten  times  as  thick  as  normal. 

In  a  case  seen  by  Fox  and  MacLeod,  and  cited  on  page  268,  there  was  a  definite 
Paget's  disease,  due  undoubtedly  to  the  irritating  discharge  from  skin  remnants  of 
the  omphalomesenteric  duct.  Fox  and  MacLeod's  patient  was  a  sailor,  sixty-five 
years  of  age,  who  came  under  the  care  of  Mr.  W.  Turner,  surgeon  to  the  Dread- 
nought Hospital  at  Greenwich.  In  the  umbilical  region  was  a  rounded,  eczematoid 
patch,  two  inches  in  diameter,  which  had  been  forming  gradually  for  eleven  years. 

On  microscopic  examination  the  outlying  portion  of  the  umbilicus  showed  the 
typical  picture  of  Paget's  disease.  The  central  portion  showed  a  covering  of  cylin- 
dric  epithelium,  and  contained  glands  resembling  those  of  Lieberkuhn.  In  this  case 
there  evidently  had  been  remains  of  the  omphalomesenteric  duct  at  the  umbilicus, 
and  the  continued  discharge  had  set  up  a  proliferation  of  the  squamous  epithelium. 
This  case  is  reported  in  detail  in  Chapter  XVII. 


LITERATURE  CONSULTED  ON  CYSTS  IN  THE  ABDOMINAL  WALL  DUE  TO  REM- 
NANTS OF  THE  OMPHALOMESENTERIC  DUCT. 

Bondi,  J.:  Zur  Kasuistik  der  Nabelcysten.     Monatsschr.  f.  Geb.  u.  Gyn.,  1905,  xxi,  729. 
Colmers,  F.:    Die  Enterokystome  und  ihre  chirurgische  Bedeutung.     Arch.  f.  klin.  Chir.,  1906, 

lxxix,  132. 
Fox  and  MacLeod:  A  Case  of  Paget's  Disease  of  the  Umbilicus.     Brit.  Jour.  Dermatol,  1904,  xvi, 

41. 
Wyss,  Hans  v. :  Zur  Kenntniss  der  heterologen  Flimmercysten.     Virchows  Arch.,  1870,  li,  143. 
Zumwinkel:    Subcutane  Dottergangscyste  des  Nabels.     Langenbeck's  Arch,  f .  klin.  Chir.,  1890, 

xl,  838. 


17 


CHAPTER  XIV. 
PERSISTENCE  OF  THE  OMPHALOMESENTERIC  VESSELS. 

Historic  sketch. 

Remnants  of  the  omphalomesenteric  vessels  at  the  mesentery. 

Omphalomesenteric  vessels  accompanying  Meckel's  diverticulum  or  a  patent  omphalomesenteric 

duct. 
Persistence  of  the  omphalomesenteric  artery  in  the  bases  of  umbilical  polyps. 
An  omphalomesenteric  vessel  lying  perfectly  free  in  the  abdomen. 
Fatal  obstruction  due  to  remnants  of  the  omphalomesenteric  vessels. 

In  the  earliest  stages  of  the  embryo  the  omphalomesenteric  arteries  are  two  in 
number.  They  arise  from  a  plexus  of  from  two  to  four  small  vessels,  coming  directly 
from  the  aorta,  and  pass  out  one  on  each  side  of  the  yolk-sac. 

The  left  artery  disappears,  the  right  persists  and  follows  the  omphalomesenteric 
duct,  to  terminate  in  a  network  which  covers  the  entire  yolk-sac.  The  proximal 
portion  of  the  right  omphalomesenteric  artery  later  becomes  the  superior  mes- 
enteric artery. 

The  omphalomesenteric  veins,  in  the  beginning,  are  two  in  number.  The  right 
disappears,  but  the  left  collects  the  blood  from  the  entire  yolk-sac  and  from  the 
omphalomesenteric  duct,  and  in  the  liver  anastomoses  with  the  left  umbilical  vein. 
Before  entering  the  liver  it  receives  tributaries  from  the  intestine — from  the  superior 
mesenteric  vein  (Fig.  7). 

A  reference  to  Fig.  6,  p.  6,  Fig.  7,  p.  7,  Fig.  8,  p.  8,  Fig.  10,  p.  10,  Fig.  11,  p.  11, 
Fig.  12,  p.  12,  Fig.  13,  p.  13,  Fig.  14,  p.  14,  Fig.  15,  p.  15,  and  Fig.  33,  p.  32,  will 
serve  to  give  a  very  clear  idea  of  the  origin  and  course  of  the  omphalomesenteric 
vessels  during  the  various  months  of  fetal  life. 

The  omphalomesenteric  vessels,  as  a  rule,  totally  disappear,  but  occasionally 
persist,  sometimes  independently,  sometimes  associated  with  remnants  of  the 
omphalomesenteric  duct  (Fig.  145).  When  one  realizes  that  in  every  human  being 
these  structures  were  at  one  time  present,  it  is  remarkable  that  remnants  of  them 
are  not  more  frequently  found. 

According  to  Fitz,  Meckel  was  familiar  with  remnants  of  the  omphalomesenteric 
vessels. 

An  observation  made  by  Ruge  in  1877  is  of  interest.  He  rejDorts  the  discovery, 
in  the  body  of  a  new-born  child,  of  a  cord  the  thickness  of  a  linen  thread  for  2  cm., 
and  then  of  hair-like  thinness  for  1.5  cm. ;  it  ran  between  the  mesentery  of  the  small 
bowel  and  the  tissue  around  the  right  umbilical  artery,  just  before  its  entrance 
into  the  abdominal  wall.  Ruge  further  described  the  projection  of  a  delicate, 
thread-like  process  with  a  knobbed  end,  from  the  mesentery  near  the  intestine,  and 
a  short  distance  above  the  cecum.  He  then  makes  the  statement  that  floating 
threads  with  rounded  ends  may  often  be  found  on  the  mesentery  or  near  the  navel, 
and  are  derived  from  the  omphalomesenteric  vessels  or  the  duct. 

Tillmanns,  in  1882,  said  that  occasionally  remains  of  the  fetal  omphalomesenteric 

242 


PERSISTENCE    OF    THE    OMPHALOMESENTERIC    VESSELS. 


243 


vessels  are  seen  as  strings  of  various  forms — threads  or  canals  extending  from  the 
inner  surface  of  the  umbilicus,  not  to  the  point  of  the  diverticulum,  but  directly  to  the 
mesentery.  Thus,  Schroeder  had  relatively  often  observed  such  pictures  in  new-born 
cats,  dogs,  and  rabbits,  although  he  acknowledged  that  they  are  more  rare  in  man. 

Fitz,  writing  in  1884,  said  that  the  vitelline  duct  is  not  only  composed  of  layers 
of  tissue  equivalent  to  those  forming  the  coats  of  the  intestine,  but  is  also  accom- 
panied by  blood-vessels.  These  are  the  omphalomesenteric  or  vitelline  arteries 
and  veins,  which  course  along  its  surface  and  ramify  over  the  walls  of  the  umbilical 
vesicle.  Coincidently  with  the  atrophy  of  the  vitelline  duct  these  vessels  also 
become  atrophied  and  eventually  disappear,  with  the  elimination  of  the  former. 
The  progressive  shrinkage  and  eventual  disappearance  of  the  vitelline  duct,  how- 
ever, do  not  necessitate  the  atrophy  of  these  vessels. 

In  Fig.  21,  p.  20,  from  a  human  embryo  12  cm.  long,  is  seen  a  small  filament 
attached  at  one  end  to  the  umbilicus,  and  at  the 
other  end  lying  perfectly  free.     It  is  a  remnant 
of  the  omphalomesenteric  vessels. 

Remnants  of  the  Omphalo- 
mesenteric Vessels  at  the  Mes- 
entery. —  Fitz  says  that  soon  after  his 
attention  had  been  drawn  to  persistence  of  the 
omphalomesenteric  vessels  he  examined  the  body 
of  a  man  who  had  died  of  chronic  tuberculosis 
at  the  Massachusetts  General  Hospital.  There 
were  two  tuft-like  projections  from  the  upper 
surface  of  the  mesentery,  each  half  an  inch  long 
and  about  half  an  inch  apart.  They  were  about 
two  inches  distant  from  the  portion  of  the  ileum 
lying  some  three  feet  above  the  ileocecal  valve. 
The  peritoneum,  covering  them  was  normal  in 
appearance,  and  the  mesentery  elsewhere  was 
free  from  all  abnormal  changes.  The  perito- 
neum in  the  vicinity  of  the  navel  was  examined, 
but  with  negative  results.  Fitz  says  that  since 
then   repeated   examinations   have  been   made 

with  reference  to  what  might  be  regarded  as  vitelline  remains,  but  with  indifferent 
success. 

Omphalomesenteric  Vessels  Accompanying  Meckel's 
Diverticulum  or  a  Patent  Omphalomesenteric  Duct. 
— Fig.  25,  p.  24,  and  Fig.  26,  p.  24,  show  very  clearly  the  relation  of  the 
omphalomesenteric  vessels  to  Meckel's  diverticulum.  Fig.  27,  p.  24,  represents 
the  same  vessels  passing  from  their  point  of  origin  to  the  umbilicus,  when  no  trace 
of  the  vitelline  duct  remains. 

Fitz  says  that  the  existence  of  the  omphalomesenteric  vessels,  their  relation 
to  the  omphalomesenteric  duct,  and  their  occasional  persistence,  entire  or  in  part, 
were  well  known  to  Meckel.  Their  transformation  into  fibrous  cords  was  likewise 
familiar  to  this  author.  He  quotes  Meckel*  as  saying:  " Quite  recently  I  found 
them  in  a  child  of  three  months,  arising,  as  usual,  from  the  superior  mesenteric 
*  Meckel:  Arch.  f.  d.  Physiologie,  1809,  ix,  439. 


Fig.  145. — An  Omphalomesenteric  Duct 
Originating  from  the  Concave  Side 
of  the  Bowel  and  Attached  to 
the  Umbilicus  by  a  Fibrous  Cord. 
(Schematic.) 

This  picture  illustrates  a  condition  that 
occasionally  exists.  The  diverticulum,  as  a 
rule,  springs  from  the  outer  or  convex  sur- 
face of  the  bowel.  The  origin  of  the  omphalo- 
mesenteric vessels  from  those  of  the  mesen- 
tery is  clearly  seen.  Where  the  omphalo- 
mesenteric duct  is  attached  to  the  umbilicus 
by  a  fibrous  cord,  this  usually  represents  the 
obliterated  portion  of  one  of  the  omphalo- 
mesenteric vessels. 


244  THE    UMBILICUS    AND    ITS    DISEASES. 

artery  and  vein,  running  along  the  entire  length  of  the  diverticulum,  and  converted 
at  its  end  into  a  solid  thread  several  inches  long  and  hanging  free. " 

Hue,  when  making  an  autopsy  on  a  child  dead  of  prolapsus  of  the  bowel  through 
a  patent  omphalomesenteric  duct,  found  a  persistence  of  the  omphalomesenteric 
artery.  Deve,  who  took  part  in  the  discussion  on  Hue's  case,  mentioned  a  case 
in  which  the  artery  also  persisted.  Stierlin,  while  removing  a  patent  omphalo- 
mesenteric duct,  noted  that  an  artery  was  injured.  It  was  isolated,  tied  off,  and 
dropped  back  into  the  abdomen.     It  was  a  patent  omphalomesenteric  artery. 

PERSISTENCE  OF  THE  OMPHALOMESENTERIC  ARTERY  IN  THE  BASES  OF 

UMBILICAL  POLYPS. 

Quite  frequently,  when  these  small  growths  are  being  cut  off,  a  vessel  spurts, 
which  is  undoubtedly  a  patent  omphalomesenteric  artery.  In  Case  2,  recorded  by 
Lannelongue  and  Fremont,  when  the  polyp  was  cut  off,  there  was  hemorrhage  from 
a  small  artery.  Pestalozza,  in  1889,  reported  a  case  in  which  the  omphalomesenteric 
vein  in  the  cord  of  a  child  at  term  was  still  patent. 

AN  OMPHALOMESENTERIC  VESSEL  LYING  PERFECTLY  FREE  IN  THE  ABDOMEN. 

One  of  the  most  interesting  cases  of  this  character  was  reported  by  Spangenberg* 
in  1819.  In  the  body  of  a  young  man,  twenty  years  old,  he  found  what  he  regarded 
as  an  open  omphalomesenteric  vessel.  It  could  be  followed  to  within  half  an  inch 
of  the  navel,  where  it  became  a  delicate  ligament  and  was  lost  in  the  umbilical  ring. 
It  descended  from  the  navel  between  the  epigastric  veins,  on  the  posterior  surface  of 
the  peritoneum,  to  which  it  was  united  by  fibrous  tissue,  to  nearly  midway  between 
the  umbilicus  and  pubes;  then,  leaving  the  wall  of  the  abdomen  as  a  thin  round 
cord,  it  crossed  the  abdominal  cavity  between  the  coils  of  small  intestine,  passed 
beneath  the  intestines  toward  the  spine,  somewhat  to  the  left,  and  emptied  into  a  bi- 
furcation of  the  main  trunk  of  the  superior  mesenteric  vein.  The  vessel  was  wholly 
free  throughout  its  entire  course,  nowhere  adhering  to  the  intestine,  and  was  envel- 
oped in  a  fibrous  sheath.  It  was  open  to  within  two  inches  of  the  navel,  and  a 
small  quantity  of  thin  blood  from  the  mesenteric  vein  was  admitted  as  far  as  its 
middle.  Its  walls  for  three  inches  from  its  origin  from  the  mesentery  were  col- 
lapsed, like  those  of  any  other  vein,  but  from  this  point  onward  the  vessel  was  of 
denser  structure  and  very  smooth  externally.  It  had  no  branches,  and  in  texture 
it  resembled  in  all  respects  the  umbilical  vein,  which  later  was  found  open  through 
half  its  course.  The  appearance  of  the  navel  as  seen  from  without  did  not  vary 
from  that  of  other  normally  formed  umbilical  depressions. 

From  the  cases  just  cited  it  is  perfectly  clear  that  one  or  both  of  the  omphalo- 
mesenteric vessels  may  persist  in  part  or  as  a  whole. 

FATAL  OBSTRUCTION  DUE  TO  REMNANTS  OF  OMPHALOMESENTERIC  VESSELS. 

Falk,  King,  and  Mahomed  have  each  recorded  a  case  in  which  the  remnant  of 
an  omphalomesenteric  vessel  appeared  to  be  the  cause  of  intestinal  obstruction. 

Fitz  referred  to  the  case  reported  by  Falkf  in  1835.     The  patient  was  a  man, 

*  Spangenberg:   Deutsches  Arch.  f.  d.  Physiologie,  1819,  v,  87. 
t  Falk:  De  Ileo  e  Diverticulis,  adieeta  Morbi  Historia,  1835,  18. 


PERSISTENCE    OF    THE    OMPHALOMESENTERIC    VESSELS. 


245 


twenty  years  of  age,  who  had  a  diverticulum  43^  inches  long.  Two  feet  above  the 
ileocecal  valve  a  solid,  pseudomembranous  ligament,  V/^  inches  long,  ran  from  its 
apex  to  the  abdominal  wall,  an  inch  from  the  umbilicus.  Uniting  the  diverticulum 
and  the  mesentery  was  a  band,  and  this  apparently  had  caused  an  intestinal  obstruc- 
tion. Falk  states  that  diverticula  in  themselves  are  not  of  much  importance  in 
producing  disturbances  of  the  intestine.  But  where  the  umbilical  vessels  are  still 
adherent  and  hang  off  as  threads  in  the  abdominal  cavity,  they  may  become  agglu- 
tinated to  the  organs  of  the  abdomen  and  thus  cause  volvulus. 

In  1843,  King  described  a  case  of  fatal  intestinal  obstruction  in  which  an  adven- 
titious cord  was  found  passing  from  the  mesentery  to  Meckel's  diverticulum.     The 
patient  was  a  boy  fourteen  months  old.     After  the  cord  came  away  on  the  eleventh 
day  there  was  a  thin,  yellow,  slightly  odor- 
ous discharge  from  the  umbilicus.     Poul- 
tices  were  used  for  three  months,  and  caus- 
tics were  applied  to  destroy  the  surface. 
The  edges  of  the  fistula  were  pared  and 
strapped.    The  opening  communicated  with 
a  deep  sinus  into  which  a  probe  passed  two 
inches,    evidently   into    the    small   bowel. 
About  seventeen  days  later  there  was  an 
escape  of  feces. 

An  ovoid  incision  was  made,  and  the 
parts  were  brought  together  with  pins  and 
plaster.  The  child  was  well  in  a  little  over 
two  weeks.  He  died  later  of  intestinal  ob- 
struction. At  autopsy  the  diverticulum 
was  found  to  be  three  inches  long  and  ad- 
herent to  the  umbilicus.  An  adventitious 
cord  had  apparently  compressed  the  ileum 
just  below  its  connection  with  the  divertic- 
ulum. 

Fig.  146  is  from  another  case  recorded 
by  King.  This  patient  also  died  from  in- 
testinal obstruction  apparently  due  to  a 
remnant  of  an  omphalomesenteric  vessel. 

Mahomed's    case,   published  in    1875, 
leaves  absolutely  no  doubt  that  the  omphalomesenteric  artery  was  responsible  for 
the  fatal  obstruction. 

The  patient  was  a  boy  eighteen  years  old  who  was  admitted  to  the  hospital  with 
signs  of  obstruction,  after  having  eaten  a  meal  of  badly  cooked  potatoes.  He  died 
with  typical  signs  of  intestinal  obstruction  eleven  days  after  the  illness  began. 

Autopsy. — A  fibrous  band  was  found  extending  from  the  middle  of  the  abdom- 
inal wall,  midway  between  the  pubes  and  the  umbilicus,  backward  toward  the  right 
iliac  fossa.  It  had  carried  out  with  it  from  the  abdominal  wall  a  triangular  fold  of 
peritoneum.  The  cord  was  found  passing  amid  the  distended  coils  of  small  intestine 
to  the  lower  part  of  the  ileum,  where  it  formed  a  noose  encircling  a  loop  of  ileum 
33  inches  in  length.  It  had  passed  one  and  a  half  times  around  the  gut  at  the  point 
of  constriction,  and  was  then  found  to  extend  to  the  mesentery  of  the  ileum,  about 


Fig.  146. — A  Remnant  of  an  Omphalomesenteric 
Duct  Causing  Fatal  Intestinal  Obstruc- 
tion.     (After  King.) 

The  figure  represents  a  Meckel's  diverticulum 
attached  to  the  convex  surface  of  a  loop  of  small 
bowel.  An  adventitious  cord  extends  from  the 
mesentery  over  the  small  bowel  to  the  side  of  the 
diverticulum.  It  represents  what  remained  of  one 
of  the  omphalomesenteric  vessels.  It  was  the  cause 
of  fatal  intestinal  obstruction. 


246  THE    UMBILICUS    AND    ITS    DISEASES. 

three  feet  from  the  ileocecal  valve.  On  being  traced  between  the  layers  of  peri- 
toneum forming  the  mesentery,  the  cord  was  discovered  terminating  in  the  large 
branch  of  the  ileocolic  artery. 

In  its  course  forward  the  fibrous  cord  was  found  to  bifurcate  at  the  apex  of  the 
triangular  fold  of  peritoneum,  which  it  had  carried  out  from  the  abdominal  wall. 
One  branch  ascended  to  the  umbilicus,  accompanying  the  obliterated  hypogastric 
artery  of  the  right  side ;  the  other  branch  descended  toward  the  bladder  and  ter- 
minated in  the  left  superior  vesical  artery. 

The  "committee"  were  of  the  opinion  that  the  case  was  one  of  persistence  of 
the  fetal  omphalomesenteric  artery,  which  sends  off  branches  of  communication 
with  the  left  superior  vesical  or  hypogastric  artery,  the  latter  having  been  prob- 
ably smaller  than  normal,  and  having  its  distribution  supplemented  by  the  former. 

On  page  169  is  a  very  interesting  account  of  a  case  of  fatal  intestinal  obstruction 
coming  under  the  care  of  Sheen.  A  large  quantity  of  small  bowel  had  passed 
through  a  hole  in  the  mesentery  of  a  Meckel's  diverticulum,  and  become  strangu- 
lated (Fig.  102,  p.  170).  A  note  was  made  that  the  strength  of  the  constricting 
cord  of  mesentery  was  largely  due  to  the  presence  of  a  vessel  that  crossed  it.  This, 
of  course,  was  one  of  the  omphalomesenteric  vessels. 

From  the  preceding  cases  it  is  clearly  evident  that  remnants  of  the  omphalo- 
mesenteric vessels  are  from  time  to  time  found,  and  that  these  may  lead  to  fatal 
intestinal  obstruction. 


LITERATURE  CONSULTED  ON  PERSISTENCE  OF  THE  OMPHALOMESENTERIC 

VESSELS. 
Fitz,  R.  H.:    Persistent  Omphalomesenteric  Remains.     Their  Importance  in  the  Causation  of 

Intestinal  Duplication,  Cyst-formation,  and  Obstruction.     Amer.  Jour.  Med.  Sci.,   1884, 

lxxxviii,  30. 
Falk,  J.:  De  Ileo  e  Diverticulis,  adiecta  Morbi  Historia,  1835,  18. 
Hue,  F. :  Prolapsus  ombilical  diverticulaire.     La  Normandie  medicale,  1906,  xxi,  162. 
King:    Feculent  Discharge  at  the  Umbilicus  from  Communication  with  the  Diverticulum  Ilei. 

Guy's  Hospital  Reports,  1843,  2.  series,  i,  467. 
Mahomed,  F.  A.:   Case  of  Intestinal  Obstruction  Produced  by  the  Abnormal  Remains  of  a  Fetal 

Vessel.     Trans.  Path.  Soc.  London,  1875,  xxvi,  117. 
Pestalozza,  E.:    Persistenza  di  un  vaso  onfalomesenterico  nel   cordone  ombelicale  di  un  feto 

a  termine.     Bull,  della  soc.  medico-chir.  di  Pavia,  1889,  11. 
Ruge,  C. :  Ueber  die  Gebilde  im  Nabelstrang.     Zeitschr.  f .  Geb.  u.  Gyn.,  1877,  i,  7. 
Spangenberg,  G.:    Beitrag  zur  Entwicklungsgeschichte  des  Darmkanals.     Deutsches  Arch.  f. 

d.  Physiologie,  1819,  v,  87. 
Tillmanns,  H. :    Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring  (Ec- 
topia ventriculi),  und  liber  sonstige  Geschwlilste  und  Fisteln  des  Nabels.     Deutsche  Zeitschr. 

f.  Chir.,  1882-83,  xviii,  161. 


CHAPTER  XV. 

UMBILICAL  CONCRETIONS  ASSOCIATED  WITH  INFLAMMATORY 
CHANGES  IN  THE  ABDOMINAL  WALL. 

Historic  sketch. 

Symptoms. 

Cause. 

Treatment. 

Cases  with  umbilical  concretions. 

Umbilical  concretions  frequently  diagnosed  as  dermoids. 

Cases  of  umbilical  horn. 

Other  foreign  substances  in  the  umbilical  depression. 

This  subject  has  been  very  carefully  considered  by  Blum,  Nicaise,  Villar, 
Foulerton,  Ledderhose,  and  Pernice.  Umbilical  concretions  seem  to  be  much  more 
frequent  in  men  than  in  women,  and  usually  occur  during  the  period  of  life  in  which 
the  patient  is  most  actively  engaged  in  work,  namely,  between  the  twentieth  and 
sixtieth  year.     They  are  exceptional  in  children  and  not  common  in  the  aged. 

As  a  rule,  the  patient  is  unaware  of  any  trouble  until  abdominal  pain  is  felt. 
This  is  usually  referred  to  the  umbilical  region,  and  may  be  increased  on  muscular 
exertion,  on  defecation,  or  on  pressure  upon  the  abdomen.  On  visual  examination 
sometimes  nothing  is  detected.  Later  induration  is  noted  in  the  umbilical  region, 
the  umbilical  opening  becomes  very  small,  and  the  surrounding  tissue  feels  hard. 
The  overlying  skin  may  or  may  not  be  reddened.  At  this  stage  the  patient  may 
have  excruciating  abdominal  pain,  followed  by  the  escape  of  a  foreign  body,  to- 
gether with  some  blood  and  pus.  A  speedy  disappearance  of  the  symptoms  usually 
follows. 

In  the  majority  of  cases  the  umbilical  depression  is  the  center  of  the  trouble, 
but  occasionally  the  swelling  and  induration  are  situated  a  short  distance  from 
it.  This  was  noted  in  Williams's  case.  The  tumor,  the  size  of  an  egg,  was 
situated  one  inch  above  the  umbilicus,  whereas  the  discharge  came  from  the 
umbilicus  itself. 

The  umbilical  opening,  as  a  rule,  is  very  small,  and  suggests  the  mouth  of  a 
fistula.  Its  margins  are  usually  flat,  but  occasionally  the  opening  is  surrounded  by 
a  zone  of  granulation  tissue,  as  noted  in  cases  reported  by  Foulerton,  Nicaise, 
Polaillon,  Richelot,  Roques,  Shattock,  and  Tremontani. 

On  examination  the  umbilical  cavity  is  invariably  found  distended  and  filled 
with  pus  and  a  concretion  or  cheesy  material.  The  cavity  itself  may  be  several 
centimeters  in  diameter.  In  Nicaise's  case  the  umbilical  depression  opened  through 
a  very  narrow  aperture  into  a  second  cavity,  which  contained  the  concretion. 

In  Taylor's  case,  when  opened  up,  the  umbilical  cavity  was  found  to  contain  an 
ounce  of  foul-smelling  pus,  and  this  cavity  communicated  with  a  second  filled  with 
a  softened,  cheesy  material  and  some  hair. 

Walters,  under  the  title  "An  Umbilical  Pocket,"  reports  a  very  instructive 

247 


248  THE    UMBILICUS   AND    ITS    DISEASES. 

case.  A  man,  aged  thirty-four,  had  complained  of  mild  periodic  attacks  of  abdom- 
inal pain.  The  umbilical  depression  led  to  a  second  pocket,  containing  a  yellowish 
mass,  which  the  patient  said  had  been  there  for  years.  The  mass  consisted  of 
sebaceous  material  and  felted  hair.  The  pocket  was  two  inches  in  diameter  and 
three-quarters  of  an  inch  deep. 

Probably  one  of  the  most  interesting  and  instructive  cases  is  that  reported  by 
Foulerton.  Protruding  from  the  umbilical  site  was  a  smooth,  solid,  round,  reddish 
growth,  the  size  of  a  cherry,  from  which  there  was  a  slight  discharge.  Surrounding 
this  was  a  zone  of  induration.  Cancer  was  suspected.  Under  local  freezing  the 
growth  was  cut  off  flush  with  the  abdominal  wall,  opening  up  an  abscess  sac 
which  contained  pus  and  a  concretion  the  size  of  a  cherry-stone.  The  red  nodule 
proved  to  be  granulation  tissue  around  the  mouth  of  a  small  fistulous  opening,  and 
the  abscess  sac  was  nothing  more  than  the  occluded  umbilical  depression.  Heal- 
ing was  complete  in  two  weeks. 

Although  the  induration  in  the  abdominal  wall  is  usually  uniform,  there  may  be 
marked  local  elevation.  In  one  instance  the  swelling  was  as  large  as  a  hen's  egg, 
and  in  the  one  described  by  Gueterbock  it  reached  the  dimensions  of  a  child's  head, 
a  large  collection  of  pus  being  present.  The  umbilical  discharge  may  be  small 
in  amount  or  very  free.  Sometimes  it  is  seropurulent,  but  usually  most  offensive, 
and  of  an  odor  suggesting  decomposing  smegma. 

The  umbilical  concretions  are  variously  recorded  as  being  the  size  of  a  pea, 
bean,  almond,  sparrow's  egg,  or  pigeon's  egg.  They  have  reached  1.5  to  2.5  cm.  or 
more  in  diameter.  They  may  be  whitish  yellow,  brown,  or  pearly  in  color.  Some- 
times they  appear  to  consist  almost  entirely  of  sebaceous  material,  and  are  exceed- 
ingly friable.  Other  concretions  are  much  firmer,  have  a  laminated  structure,  pre- 
sent a  pearly  appearance,  and  constitute  what  Coenen  has  termed  cholesteatomata. 
The  surface  of  these  concretions  may  be  perfectly  smooth,  or  small  hairs  may  be 
seen  projecting  from  their  surfaces.  These  hairs  may  be  colorless  or  correspond 
in  color  to  those  of  the  patient.  The  cheesy  material  sometimes  contains,  in  addi- 
tion, other  foreign  material,  such  as  wool  or  cotton  fibers  from  the  patient's  clothing 
and  particles  of  such  matter  as  clay,  coal,  or  stone,  according  to  the  occupation  of 
the  individual.  On  histologic  examination  the  cheesy  material  is  seen  to  consist 
of  fatty  desquamated  epithelium,  and  in  some  cases  keratin,  fatty  debris,  and 
cholesterin  crystals  are  also  found. 

The  cause  of  these  umbilical  inflammations  is  easy  to  explain.  Owing  to  lack 
of  cleanliness  or  to  an  unusually  deep  umbilicus,  particles  of  hair  or  wool  accumulate 
deep  m  the  umbilical  depression.  These  form  a  small  ball,  which  in  turn,  by  its 
irritation,  causes  exfoliation  of  the  squamous  epithelium.  This  adheres  to  the 
mass  and  gradually  increases  its  size.  Finally,  as  a  result  of  the  constant  irritation, 
there  ensues  a  mild  inflammation  of  the  tissue  surrounding  the  umbilicus,  which 
gradually  narrows  the  umbilical  opening  until  it  becomes  but  little  larger  in  diam- 
eter than  a  fistulous  tract.  Pus  accumulates  and  dilates  the  umbilical  depression, 
and  an  abscess  cavity  containing  a  concretion  results. 

This  condition  rarely  leads  to  serious  consequences.  In  one  of  Volkmann's* 
cases,  however,  it  would  seem  that  the  long-continued  irritation  of  the  concretion 
had  induced  a  primary  carcinoma  of  the  umbilicus. 

The  history  of  these  cases  is  characteristic,  and  there  should  be  little  difficulty 
*  Volkmann  (Cited  by  Pernice) :    Die  Nabelgeschwtilste,  Halle,  1892. 


UMBILICAL    CONCRETIONS. 


249 


A./i. 

Fig.  147. — A  Small  Umbilical  Concretion. 
From  a  woman,  ninety-seven  years  of  age, 
seen  at  the  Church  Home  June  4,  1910.  The 
umbilical  opening  was  small;  completely  fill- 
ing it  was  a  small  black  mass,  which  on  pres- 
sure was  partly  forced  out.  It  consisted  of 
cheesy  material.  The  superficial  portion  had 
become  black  as  a  result  of  exposure  to  the 
light,  air,  and  dust. 


in  establishing  the  diagnosis.     In  Foulerton's  case,  however,  the  condition  was  sup- 
posed to  be  one  of  carcinoma  of  the  umbilicus. 

Treatment.  —  This  consists  in  widely  dilating  the  fistulous  tract  with  the 
full  knowledge  that  in  the  depth  a  concretion 
or  caseous  material  or  both  will  be  found. 
Thorough  removal  of  the  foreign  substance  is 
invariably  followed  by  prompt  recovery,  but  as 
long  as  portions  remain  there  will  be  a  discharge. 
Occasionally  an  umbilical  concretion  may  be 
present  without  producing  any  inflammatory 
reaction.  On  June  4,  1910,  I  saw  a  patient 
ninety-seven  years  of  age  at  the  Church  Home, 
Baltimore.  The  umbilicus  was  exceedingly 
small;  projecting  from  it,  and  completely  filling 
the  opening,  was  a  small  black  mass  (Fig.  147) . 
The  house  officer  suspected  a  malignant  growth. 
On  making  pressure  I  forced  the  mass  farther 
out.  The  deeper  portions  presented  the  char- 
acteristic cheesy  character  of  a  concretion. 
The  superficial  portion  had  become  hard  and 
black  on  account  of  exposure  to  the  light,  air, 
and  dust. 

While  analyzing  this  group  of  cases  the  following  case  came  under  my  care: 
Mr.  S.  W.,  aged  thirty-two,  was  seen  on  March  31,  1913.  This  patient  had  been 
ill  for  two  weeks;  previous  to  this  time  he  had  been  perfectly  well.  On  examina- 
tion I  found  the  umbilicus  pout- 
ing out  like  a  snout.  It  projected 
out  about  1  cm.,  and  from  its 
center  there  was  a  discharge  of 
creamy  pus.  The  opening  from 
which  this  pus  escaped  was  about 
2  mm.  in  diameter.  The  abdom- 
inal wall  on  each  side  was  indur- 
ated over  an  area  of  about  3  cm., 
and  there  was  a  distinct  flush. 
Fig.  148  is  a  water-color  sketch 
of  the  condition.  On  pressure  the 
parts  were  found  to  be  indurated 
and  there  was  a  good  deal  of  dis- 
comfort. I  felt  sure  that  we  were 
dealing  with  an  accumulation  of 
sebaceous  material,  and  that  this 
had  caused  an  acute  inflamma- 
tion. 

Bichlorid  compresses  were  ap- 
plied for  forty-eight  hours.  The  patient  was  then  brought  to  the  operating-room, 
and  with  a  pair  of  Kelly  forceps  the  opening  at  the  umbilicus  was  stretched.  We 
then  used  a  sharp  curet  and  brought  away  quantities  of  sebaceous  material.     The 


Fig.  148. — Acute  Inflammation  op  the  Umbilicus  due  to  an 
Accumulation  of  Sebaceous  Material. 
The  umbilical  depression  is  raised  and  tense.  Near  its  cen- 
ter pus  is  seen  escaping  from  a  small  orifice.  The  surrounding 
abdominal  wall  is  swollen,  red,  and  indurated.  The  small  open- 
ing was  stretched  considerably,  and  the  cavity  evacuated.  A 
large  quantity  of  cheesy  material  was  cureted  away.  The  cavity 
was  packed  with  gauze.  The  inflammation  speedily  subsided,  and 
in  a  few  weeks  the  umbilicus  presented  the  normal  appearance. 


250  THE    UMBILICUS    AND    ITS    DISEASES. 

cavity  was  packed  with  iodoform  gauze.  From  clay  to  day  the  wound  was  washed 
out  with  hydrogen  dioxid.  The  patient  was  discharged  on  April  5,  1913.  On  April 
21st  the  umbilicus  presented  the  normal  appearance,  and  there  was  not  the  slightest 
trace  of  inflammation  or  of  discharge. 


CASES  WITH  UMBILICAL  CONCRETIONS. 

In  some  cases  I  have  given  an  exact  translation  of  the  original  title,  although  on 
careful  examination  of  the  description  of  the  case  it  is  evident  that  the  patient  was 
suffering  from  an  umbilical  concretion  and  not  from  a  dermoid  cyst,  as  diagnosed  by 
the  individual  author. 

Tuberculosis  o  f  t  h  e  Umbilicusf?].*  —  Ten  days  before  the 
patient  had  had  cramp-like  pains  in  the  abdomen,  followed  in  three  days  by  a  dis- 
charge from  the  umbilicus,  accompanied  by  tenderness  and  soreness  in  that  region. 
His  sisters  had  died  of  tuberculosis.  There  was  a  purulent  discharge  from  the  um- 
bilicus and  slight  swelling  to  the  right  and  below  it,  apparently  in  the  deeper  por- 
tion of  the  abdominal  wall. 

At  operation  the  umbilical  opening  was  enlarged,  and  over  an  ounce  of  "typical 
tuberculous  "  granulation  tissue  removed.  The  cavity,  the  size  of  a  walnut,  internal 
to  the  abdominal  wall  was  exposed  and  packed  with  iodoform  gauze. 

Smears  of  this  showed  numerous  "tubercle  bacilli"  in  some  specimens,  none  in 
others.  Bouffleur  questioned  whether  he  was  dealing  with  a  primary  tuberculosis 
of  the  blind  urachus  or- Meckel's  diverticulum  or  with  a  primary  umbilical  tuber- 
culosis. 

[The  history  of  the  case  and  the  findings  at  operation  would  rather  suggest 
an  accumulation  of  sebaceous  material  at  the  umbilicus  than  any  tuberculous 
process.     The  acid-fast  organisms  found  were  possibly  smegma  bacilli.- — T.  S.  C] 

Umbilical  Concretions. f  —  In  two  cases  of  phlegmonous  inflam- 
mation of  the  umbilical  region  with  fistula,  Bufalini  found  at  the  bottom  of  the 
abscess  stony  concretions  which  consisted  of  fatty  and  gritty  particles,  of  carbonic 
acid  chalk,  exfoliated  epithelium,  and  threads  from  clothing. 

Cholesteatomata  of  the  Umbilicus.  —  Coeneni  said  that  in 
the  last  two  years  two  cases  of  "pearl  tumor"  of  the  umbilicus  had  been  seen  in 
Kiittner's  clinic.  The  first  had  already  been  reported  in  Brun's  Beitrage,  Bd. 
lviii,  Hft.  3. 

Case  1. — The  patient,  forty-nine  years  old,  had  a  purulent  discharge  and  a 
general  phlegmonous  condition  in  the  region  of  the  umbilicus.  Slight  jaundice 
developed  and  the  umbilicus  became  very  prominent.  An  incision  was  made,  and 
an  abscess  cavity  the  size  of  a  hen's  egg  was  found  at  the  umbilicus.  This  contained 
a  tumor  the  size  of  a  pigeon's  egg  (Fig.  149).  It  was  made  up  of  concentric  layers 
of  glistening  mother-of-pearl  tissue.  These  layers  were  arranged  just  as  the  various 
layers  of  an  onion,  and  consisted  of  hornified  epithelium.  The  process  was  com- 
plicated by  suppuration. 

Case  2. — A  man  of  strong  build,  aged  twenty-five,  a  few  days  before  admission 

*  Bouffleur:   Clinical  Review,  Chicago,  1898,  ix,  329. 
t  Bufalini,  G.:  Jahresbericht  der  gesammt.  Med.,  1887,  ii,  497. 

i  Coenen,  H.:  Ueber  das  Cholesteatom  des  Nabels.  Beitrage  zur  klin.  Chir.,  1908,  lviii, 
718;  Munch,  med.  Wochenschr.,  1909,  lvi,  II,  1583. 


UMBILICAL    CONCEETIONS. 


251 


Fig.    149.  —  Cholestea- 
toma from  the  Um- 
bilicus   in    Case    1. 
(After  Coenen.) 
From  the  description, 
this  is  apparently  the  nat- 
ural size.    It  was  described 
as  being  the  size  of  a  pig- 
eon's egg. 


to  the  hospital  had  noticed  at  the  umbilicus  a  swelling  from  which  purulent  fluid 
escaped.  At  the  umbilicus  was  a  smooth,  pea-sized  elevation,  reddish  in  color, 
soft  in  consistence.  When  slight  pressure  was  made  on  the  umbilical  funnel,  there 
escaped  a  body  the  size  of  an  acorn  (Fig.  150).  It  had  a  mother-of-pearl,  glistening 
appearance,  was  composed  of  horny  layers,  and  at  once  brought  to  mind  the  pre- 
vious case  of  cholesteatoma  of  the  umbilicus.  With  the 
patient  anesthetized,  the  posterior  surface  of  the  umbilical 
ring  was  found  adherent  to  the  gastrocolic  ligament.  These 
adhesions,  together  with  the  ligamentum  teres  and  the  obliter- 
ated urachus,  were  cut  through.  The  umbilicus,  which  con- 
tained a  small  tumor  the  size  of  a  hazel-nut,  was  removed.  The 
abdomen  was  closed,  and  healing  took  place  without  difficulty. 
Histologically,  the  tissue  lying  in  the  umbilical  funnel 
consisted  of  markedly  proliferating  fibrous  tissue  with  abun- 
dant small-round-cell  infiltration  and  cells  around  the  blood- 
vessels. Covering  the  surface  of  the  fibrous  tissue  was  a 
very  thick  layer  of  epithelium.  This  had  exfoliated  quan- 
tities of  horny  epithelium,  so  that  in  the  space  between  this 
projection  and  the  wall  of  the  umbilical  ring  there  was  a 
large  amount  of  horny  epithelium.  The  connective  tissue 
itself  showed  marked  subepithelial  cell  proliferation,  just  as  is 
seen  in  the  vicinity  of  carcinomatous  prolongations.  Never- 
theless, no  carcinomatous  infiltration  by  the  epithelium  could 
be  definitely  made  out. 

Sections  from  the  cholesteatoma  stained  with  Gram  were  intensely  blue.  The 
cells  shewed  keratin  bodies.  In  the  umbilical  funnel  there  was  a  knob-like  fibroma 
(Figs.  151  and  152).  There  was  marked  proliferation  of  its  epithelial  covering, 
and  there  had  been  a  continual  throwing  off  of  layers  of  epithelium  into  the  umbil- 
ical depression.  This  desquamated  epithelium  was  held  in  the  umbilicus,  the 
fibroma  acting  as  a  cork  to  the  umbilical  opening.  In  layer  after 
layer  the  exfoliated  epithelial  cells  had  accumulated  into  a  large 
plaque,  forming  the  cholesteatomatous  mass.  Probably  this  proc- 
ess had  existed  for  years,  but  was  only  noted  by  the  patient  when 
an  abundant  purulent  discharge  took  place. 

According  to  Coenen,  the  primary  cause  in  this  second  case 
of  cholesteatoma  of  the  umbilicus  was  without  doubt  the  presence 
of  the  fibrous  tumor  in  the  umbilical  depression.  The  continuous 
irritation  of  the  products  of  the  cholesteatoma  in  the  umbilical 
ring  could  now  easily  lead  to  an  eczematous  inflammation  of  the 
skin  of  the  umbilicus,  to  abscess  formation,  and  to  phlegmon. 

Cholesteatoma  of  the  Umbilicus.  —  Coenen  * 
described  a  case  from  Kuttner's  clinic.  A  woman,  sixty-two  years 
old,  had  a  pendulous  abdomen  and  lax  abdominal  walls.  When  the  various  folds 
were  drawn  away  from  one  another,  there  was  seen  in  the  umbilicus  the  characteristic 
pearly,  glistening  epithelial  exfoliation  noted  in  a  cholesteatoma.  The  growth  could 
be  lifted  out  with  a  spoon  and  appeared  as  small  balls  the  size  of  a  pea  or  of  a  bean. 
If  the  material  had  remained  longer,  it  would  have  developed  into  a  cholestea- 

*  Coenen,  H.:  Loc.  cit. 


Fig.  1.50. — Choles- 
teatoma FROM 
Case  2.  (After 
Coenen.) 

It  was  the  size  of  an 
acorn. 


252 


THE    UMBILICUS    AND    ITS    DISEASES. 


toma.  In  this  case  there  was  a  desquamative  omphalitis  with  an  accumulation  of 
cholesteatomatous  masses  in  the  umbilical  ring.  Coenen  calls  attention  to  the 
analogy  between  cholesteatoma  of  the  umbilicus  and  cholesteatoma  of  the  ear. 


Fig.  151. — The  Coxxective-tissue  Projection"  Really   Represexts  a  Small  Fibroma  in  the  Floor  of  the 

Umbilicus.      (After  Coenen.) 

It  consists  of  fibrous  tissue  showing  marked  small-round-cell  infiltration.     The  covering  consists  of  many  layers  of 

squamous  epithelium,  superficial  portions  of  which  are  horny. 


'     . 


Fig.  152. — Exlargemext  of  Fig.  151.     (After  Coenen.) 
The  excessive  thickening  of  the  squamous  epithelium  in  the  umbilical  depression  is  shown.     The  center  of  the 
epithelial  areas  shows  hornification.      The  underlying  tissue  shows  small-round-cell  infiltration,  particularly  well  seen 
around  the  capillaries. 


Fistulous   Abscess   of   the    Umbilicus.*  —  A  digger,  forty-six 
years  of  age,  had  always  been  healthy  except  for  a  pleurisy  at  four  years  of  age.     He 
said  that  fifteen  days  before  coming  under  observation  he  had  had  pain  in  the 
*  Derville,  L. :  Abces  fistuleux  do  I'ombilic.     Jour.  d.  sci.  med.  de  Lille,  1894,  ii,  320. 


UMBILICAL    CONCRETIONS.  253 

umbilical  region,  and  at  the  same  time  a  serous  discharge  from  the  umbilicus.  The 
pain  increased  greatly,  and  after  the  application  of  poultices  a  grayish  piece  of 
stone  the  size  of  a  pea  came  away.     A  probe  was  passed  to  a  depth  of  2  cm. 

A  Sebaceous  Umbilical  Tumor.*  —  At  autopsy  on  a  stout 
woman,  seventy-five  years  of  age,  a  small,  elongate  tumor  at  the  umbilicus,  with  a 
little  opening,  was  found.  A  probe  introduced  into  this  opening  was  arrested  by 
a  yellow,  very  hard  body.  An  incision  showed  that  the  cavity  was  continuous  with 
the  skin.  The  body  in  this  cavity  was  ovoid  in  form,  the  size  of  an  almond,  whitish 
yellow,  and  sticky.     It  had  the  odor  of  infected  smegma. 

On  microscopic  examination  it  was  found  to  consist  of  cholesterin  and  an  accu- 
mulation of  exfoliated  epithelium. 

Growths  from  the  Umbilicus. f  —  A  dockyard  laborer,  aged 
forty-nine,  had  protruding  from  the  site  of  the  umbilicus  a  smooth,  solid,  round 
growth  the  size  of  a  cherry.  This  had  a  covering  resembling  mucous  membrane, 
and  from  it  there  was  slight  discharge.  Its  base  was  somewhat  constricted,  but 
there  was  no  definite  pedicle,  and  no  sulcus  could  be  detected  between  the  growth 
and  the  surrounding  skin.  Around  the  growth  was  a  zone  of  uniform  induration 
extending  for  an  inch  and  a  quarter  in  every  direction,  involving  the  skin  and  sub- 
cutaneous tissue.  The  skin  over  the  indurated  region  was  of  the  natural  appear- 
ance, adherent  to  the  subcutaneous  tissue,  and  extremely  tender.  The  patient 
thought  that  his  umbilicus  had  always  been  smaller  than  usual,  but  had  noticed 
nothing  else  until  three  weeks  previously,  when  a  very  painful  lump  had  suddenly 
appeared  there.  The  lump  was  considerably  smaller  when  he  first  saw  it  than  on 
admission.  The  pain  had  been  extreme  and  continuous.  The  surgeon  who  sent 
him  to  Foulerton  had  diagnosed  cancer,  and,  as  a  matter  of  fact,  the  growth  had 
every  appearance  of  epithelioma.  The  pain  had  been,  however,  too  acute  in  its 
commencement  and  in  its  intensity.  The  growth  was  removed  at  the  level  of  the 
skin  under  the  ether  spray,  and  a  cavity  was  exposed.  This  contained  some  thin, 
purulent  fluid,  and  a  hard  mass  of  inspissated  sebaceous  material  the  size  of  a 
cherry-stone.  The  cavity  admitted  the  tip  of  the  finger;  it  was  laid  open,  scraped 
out,  and  a  poultice  was  applied.'  Four  days  later  the  induration  was  gone  and 
the  wound  healed  up  in  two  weeks.  Foulerton  draws  attention  to  his  article  in 
the  Lancet  of  July  7,  1888,  in  which  he  described  four  intractable  umbilical  sinuses 
due  to  concretions.     No  microscopic  examination  was  made  in  this  case. 

Dermoid  Cysts  of  t  heUmbilicus  [?].j  — -A  man,  thirty-five  years 
of  age,  entered  the  hospital  for  umbilical  suppuration.  About  five  months  before 
a  small  tumor  had  been  noted  at  the  umbilicus.  This  had  reached  the  size  of  a 
walnut  and  was  slightly  painful.  It  had  been  incised  a  month  before  admission, 
and  a  caseous  mass  and  a  tuft  of  hair  had  escaped.  Gonard  found  the  umbilicus 
indurated  and  red;  the  orifice  was  very  small,  and  from  it  drops  of  pus  escaped. 
A  probe  was  passed  2  cm.  into  the  depth,  and  the  sac  dissected  out.  Gonard 
thought  it  was  a  dermoid  cyst  on  account  of  the  hair  and  the  inner  lining. 

[Probably  the  case  was  one  of  inflammation  due  to  the  presence  of  a  foreign 
body.— T.  S.  C] 

*  Fere,  C. :  Tumeur  sebacee  ombilical.     Bull.  Soc.  anat.  de  Paris,  1875, 1,  622. 

t  Foulerton,  A.  G.  R.:  Illustrated  Med.  News,  1889,  iv,  161. 

t  Gonard,  G. :  Des  kystes  dermoides.     These  de  Alontpellier,  1906,  No.  31. 


254  THE    UMBILICUS    AND    ITS    DISEASES. 

A  Dermoid  Tumor  of  the  Umbilicus  [?].  *  — -A  girl  of  sixteen 
had  noticed  a  swelling  in  the  abdomen  fourteen  days  before  coming  under  observa- 
tion. During  the  last  eight  days  this  had  rapidly  increased  in  size.  On  admission 
it  was  the  size  of  a  child's  head,  round,  and  at  several  points  markedly  nodular. 
It  was  situated  in  the  mid-line,  was  easily  grasped,  was  firm,  not  very  elastic,  some- 
what movable,  and  slightly  painful  on  pressure.  Three  days  later  fever  developed, 
and  after  two  days  more  redness  and  fluctuation  were  noted.  On  the  following 
day  there  was  an  abundant  quantity  of  thin  pus  coming  from  an  irregular  hole  in 
the  tumor.  Sebaceous  masses  and  portions  of  a  thin  membrane  were  then  removed. 
The  tumor,  after  its  contents  had  escaped,  became  markedly  smaller  and  gradually 
disappeared.  Microscopic  examination  showed  free  nuclei,  granules,  cholesterin 
crystals,  and  fat. 

[If  it  had  been  a  dermoid,  why  had  it  appeared  so  suddenly  and  why  did  it 
disappear  completely,  although  all  the  wall  was  certainly  not  removed?  Was  it 
not  more  probably  an  abscess? — T.  S.  C] 

An  Umbilical  Concretion  the  Size  of  a  Pigeon's  Egg. 
—  Hahnf  says  concretions  of  the  umbilicus  occurring  as  a  result  of  lack  of  cleanli- 
ness are  not  rare.  His  patient,  a  joiner,  forty-three  years  old,  fourteen  days  before 
he  came  under  observation  had  noticed  a  painful  swelling  at  the  umbilicus.  The 
skin  was  unchanged.  For  four  days  before  Hahn  saw  him  pus  had  been  escaping 
from  the  umbilicus.  On  examination  a  swelling  on  the  right  side  of  the  umbilical 
depression  was  found,  and  a  tumor  the  size  of  a  walnut,  circumscribed,  smooth, 
firm,  and  painful  on  manipulation.  There  was  an  escape  of  thick,  greenish,  foul 
pus  in  small  quantities.  The  sound  passed  2  cm.  downward  and  to  the  right. 
After  a  few  days  there  was  edema  of  the  skin  and  a  slight  elevation  of  temperature. 

A  transverse  incision  was  made  to  the  right.  Pus  with  whitish,  friable  particles 
escaped.  In  the  depth  was  a  roundish,  whitish,  glistening  tumor,  the  size  of  a 
pigeon's  egg,  which  was  easily  removed.  It  was  3  cm.  long  and  2  cm.  broad.  It 
was  yellowish  white,  rather  firm,  and  friable.  It  had  an  outer  covering  3  to  4  mm. 
thick,  with  a  blackish  central  portion.  On  histologic  examination  it  was  found  to 
be  composed  of  horny  epithelium,  fat,  sebaceous  masses,  dirt,  and  particles  of  coal. 
The  dark  center  had  the  same  constituents  and  also  contained  wool  fibers.  Hahn 
draws  attention  to  the  fact  that  such  concretions  are  often  confused  with  suppurat- 
ing dermoids. 

An  Umbilical  Concretion.  — -  According  to  Ledderhose,t  Gilbert 
described  a  concretion  which  was  composed  of  lamellae.  It  showed  amorphous 
and  crystalline  fat,  leukocytes,  and  fragments  of  chalk. 

An  Umbilical  Concretion.  §  —  Duplay's  patient  was  a  stout, 
elderly  woman.  At  autopsy,  at  the  umbilical  level  there  could  be  felt  a  small, 
elongate  tumor  directed  obliquely  downward  and  then  backward.  This  occupied 
a  fatty  pocket.     The  upper  portion  of  the  umbilical  wall  was  intact.     When  the 

-1  Gueterbock,  P.:  Ueber  einen  Fall  von  Dermoidgeschwulst  cles  Nabels.  Deut.  Zeitschr. 
f.  Chir.,  1891,  xxxii,  319;  Deutsche  med.  Wochenschr.,  1891,  xvii,  1079. 

t  Halm,  Otto:  Ein  Nabelkonkrement  von  Taubeneigrosse.  Beitrage  z.  klin.  Chir.,  1900, 
xxvi,  80. 

i  Ledderho.se,  G.:  Chirurgische  Erkrankungen  des  Nabels.  Deutsche  Chirurgie,  1890,  Lief. 
45  b. 

§  Nicaise:  Ombilic.  Dictiormaire  encyclopedique  des  sci.  med.,  Paris,  2.  ser.,  xv,  1881, 
140. 


UMBILICAL   CONCRETIONS.  255 

margins  of  the  cutaneous  depression  were  separated,  at  the  bottom  could  be  seen 
a  small  opening  a  little  over  1  mm.  in  diameter.  A  probe  introduced  impinged 
upon  a  foreign  body  which  was  yellowish  in  color.  An  incision  was  made,  and  at 
the  umbilical  cicatrix  was  found  a  sac-like  formation  containing  a  hard,  homoge- 
neous body  the  size  of  an  almond  and  consisting  of  sebaceous  material. 

An  Umbilical  Concretion.  —  Nicaise *  r eports  the  following  case, 
seen  by  Notta,  in  which  an  accumulation  of  sebaceous  material  had  given  rise  to 
an  inflammation  of  the  umbilicus.  A  shoemaker,  aged  fifty-six,  had  previously 
had  excellent  health.  Two  years  before  he  had  noticed  at  the  umbilicus  a  hardness 
without  any  change  in  color  of  the  skin  and  without  any  discharge.  This  hardness 
had  increased  in  volume  very  slowly,  and  only  later  had  become  painful.  At  last  he 
could  not  bear  the  clothes  to  come  in  contact  with  the  part,  and  his  work  naturally 
augmented  the  pain.  He  was  not  able  to  hold  the  shoe  against  his  umbilicus,  as 
is  the  custom  with  shoemakers,  but  was  obliged  to  work  with  it  applied  to  another 
part  of  the  abdomen.  About  June  10,  1878,  the  pain  had  become  more  severe, 
the  skin  had  reddened,  ulceration  had  occurred  in  the  center  of  the  umbilicus,  and 
a  small  amount  of  pus  had  escaped  until  a  fragment  of  a  sebaceous  calculus,  the 
size  of  a  filbert,  had  come  away  spontaneously,  and  the  pain  had  ceased.  His 
physician  later  had  extracted  several  fragments.  When  called  in  consultation, 
Notta  found  the  umbilicus  tumefied  and  the  skin  red  and  indurated  for  a  distance 
of  from  12  to  15  cm.  around  it.  In  the  center  was  an  area  of  ulceration  15  mm.  in 
diameter,  at  the  bottom  of  which,  bathed  in  pus,  was  a  whitish  mass.  After  enlarg- 
ing the  opening  Notta  extracted  the  whitish  mass,  the  size  of  a  walnut,  which  con- 
sisted of  hard  sebaceous  material.  Linseed  poultices  were  applied  for  twenty-four 
hours,  and  later  lint  steeped  in  aromatic  wine.  The  umbilicus  healed  rapidly. 
The  cause  of  this  affection,  according  to  Notta,  was  very  simple.  Sebaceous  mate- 
rial had  accumulated  in  the  deep  folds  of  the  umbilicus,  and  little  by  little  had  con- 
densed to  form  a  mass  having  the  appearance  of  a  calculus.  This  had  produced 
an  inflammation  which  had  caused  the  elimination. 

Inflammation  in  the  Umbilical  Depression.  —  Park'sf 
patient  was  thirty  years  old,  and  for  two  or  three  years  had  had  a  slight  but  con- 
stant discharge  from  a  small  opening  at  the  umbilicus.  At  no  time  had  this  had  a 
fecal  or  urinary  odor.     It  was  seropurulent  in  character,  and  excoriated  the  parts. 

The  cavity  was  slit  open  with  a  probe  as  a  guide.  It  had  the  diameter  of  an 
almond,  and  had  glistening  walls;  it  contained  no  hair  or  epithelial  products.  Park 
thought  it  was  a  dermoid.  The  cavity  was  scraped  out,  packed,  and  partly  closed. 
Healing  took  place. 

[In  this  case  there  had  evidently  been  a  simple  inflammatory  condition. — 
T.  S.  C] 

Umbilical  Concretion.  — Pernice J  reports  a  case  of  Longuet's.§ 
A  young  woman  had  a  swelling  at  the  umbilicus  for  three  weeks.  At  first  there 
was  no  pain.     Later  it  began  to  suppurate.     Three  days  after  the  patient's  entrance 

*  Nicaise:  Op.  cit. 

f  Park,  Roswell:  Clinical  Lecture  on  Congenital  Fistulae  and  Sinuses  at  the  Umbilicus. 
Med.  Fortnightly,  1896,  ix,  9. 

t  Pernice,  L. :   Die  Nabelgeschwulste,  Halle,  1892. 
§  Longuet:   Bull.  Soc.  anat.  de  Paris,  1875. 


256  THE    UMBILICUS    AND    ITS    DISEASES. 

to  the  hospital,  as  a  result  of  the  introduction  of  a  sound,  a  foreign  body  was  expelled. 
It  was  the  size  of  an  almond,  hard,  made  up  of  epithelial  masses  and  fatty  crystals. 

Umbilical  Concretions.*  — A  man,  forty  years  of  age,  after 
muscular  exercise  had  felt  something  give  way  in  the  region  of  the  umbilicus,  and 
after  that  had  had  pain  there.  The  umbilicus  was  red,  swollen,  and  projected  3  cm. 
from  the  abdomen.  From  it  there  escaped  a  foul-smelling  discharge.  On  pressure 
two  bodies  the  size  of  beans  were  forced  out.  They  consisted  entirely  of  matted 
hair. 

Suppurating  Dermoid  Cyst  of  the  Umbilical  Re- 
gion [  ?  ]  .  f  —  A  woman,  thirty  years  of  age,  presented  a  tumor  in  the  umbilical 
region.  When  one  year  old,  she  had  had  a  blow  on  the  umbilicus.  For  several  days, 
during  the  six  weeks  before  she  was  admitted,  her  abdomen  had  continually  come  in 
contact  with  the  wash-tub.  For  about  three  days  she  had  had  pain  in  the  umbilical 
region.  A  few  days  later  she  had  noticed  a  discharge  from  the  umbilicus  and  a 
swelling  for  a  distance  of  2  cm.  around  the  umbilical  region.  Squeezing  caused  a 
moderate  amount  of  pus  to  escape  from  the  umbilicus.  On  admission  there  was 
an  elevated  area  of  proud  flesh  the  size  of  a  pigeon's  egg.  The  umbilicus  was  red 
and  thickened;  fluctuation  was  evident.  An  incision  evacuated  pus  and  grumous 
material.  A  probe  passed  4  cm.  downward.  The  cavity  was  irrigated.  About 
two  weeks  later  a  sebaceous-like  mass,  the  size  of  a  walnut,  escaped. 

[The  condition  suggests  a  foreign  body  or  a  concretion  rather  than  a  dermoid. 
— T.  S.  C] 

Subumbilical  Tuberculous  Abscesses  [?].|  — ■  Case  1 .  A 
man,  thirty-five  years  old,  had  complained  of  swelling  in  the  umbilical  region  for 
about  a  month.  He  had  vomiting,  and  pain  at  the  umbilicus.  Following  this  there 
had  developed  a  painful  swelling,  but  when  his  physician,  thinking  it  was  a  hernia, 
had  attempted  to  reduce  the  mass  by  taxis,  pus  had  escaped  from  the  umbilicus. 
Since  then  there  had  been  a  fistulous  opening  and  a  phlegmonous  induration  of  the 
region.  The  patient's  general  condition  was  good.  The  tumefaction  was  exactly 
in  the  median  line  and  symmetric.  A  probe  could  be  introduced  only  with  diffi- 
culty, except  when  curved.  A  sound  passed  7  or  8  cm.  below  the  umbilicus,  both  to 
the  right  and  left. 

The  tumor  opened  toward  the  right  side,  and  one  day  a  large  mass  of  caseous 
material  came  away.  The  opening  closed,  and  the  patient  left  the  hospital.  Six 
months  later  there  was  pain  in  the  abdomen,  but  nothing  was  noted  at  the  umbilicus. 

Ten  years  before  the  patient  had  had  inflammation  of  the  left  lung  and  a  pleuro- 
pneumonia on  the  right  side  five  years  later,  but  never  a  hemorrhage.  Ausculta- 
tion was  negative. 

[The  history  of  the  case  and  the  character  of  the  discharge  strongly  indicate 
an  accumulation  of  sebaceous  material  in  the  umbilicus.  Had  tuberculosis  existed, 
one  would  hardly  have  expected  the  cavity  to  have  closed  so  satisfactorily. — T.  S.  C] 

Case  2. — Richelot  reports  a  personal  communication  from  Verneuil.  A  Sister 
of  Charity,  who  had  had  scrofula  as  a  child  and  also  an  old  coxalgia,  received  a  con- 
tusion beneath  the  umbilicus  when  using  a  good  deal  of  force  in  closing  a  drawer. 

*  Pernice,  L.:  Op.  cit.     Labalbary:  Gaz.  des  hop.,  1862,  443. 

t  Polaillon:  Kyste  dermoi'de  suppure  de  la  region  ombilicale.  Gaz.  med.  de  Paris,  1886, 
lvii,  43.5. 

%  Richelot,  L.  G.:  Abces  tuberculeux  sous-ombilical.     L'union  med.,  1883,  xxxv,  61. 


UMBILICAL   CONCRETIONS.  257 

Several  weeks  later  a  fluctuating  tumor  was  noted  at  the  umbilicus.  It  was  incised, 
and  a  large  quantity  of  milk-like  fluid  escaped.  A  fistula  developed  several  months 
later;  she  began  to  cough,  and  finally  died  of  tuberculosis. 

An  Umbilical  Concretion.*  —  The  patient,  fifty  years  old,  had 
been  previously  in  good  health.  The  umbilicus  formed  a  deep  cul-de-sac  surrounded 
by  a  red  and  tumefied  zone.  It  was  painful  on  pressure.  The  pain  was  increased 
on  movement  or  on  defecation.  Applications  were  made,  and  later  there  was 
a  discharge  of  seromucous  fluid  and  a  small  body  came  away.  The  symptoms 
rapidly  subsided.  This  nodule  was  spheric,  the  size  of  a  hazelnut,  and  hard.  On 
section  it  showed  black  and  white  areas.  The  black  particles  occupied  the  center; 
the  whitish  areas  were  soluble  in  ether. 

[There  were  evidently  foreign  bodies  associated  with  an  accumulation  of  epi- 
thelium.—T.  S.  C] 

An  Umbilical  Concretion,  f  —  A  soldier,  thirty-two  years  of  age, 
complained  of  pain  at  the  umbilicus  for  fifteen  days.  The  pain  was  extreme  and 
there  was  a  certain  amount  of  heat  in  the  depth  of  the  tissue.  Surrounding  the  um- 
bilicus was  a  tumefied  and  red  area.  When  a  probe  was  introduced,  a  sensation  of 
a  hard  body  in  the  depth  could  be  made  out  and  an  abundant  amount  of  sebaceous 
material  escaped.  At  the  end  of  five  days  a  probe  could  be  introduced  7  cm.  On  the 
twentieth  day  there  were  violent  contractions,  accompanied  by  severe  pain,  and 
a  foreign  body  escaped  with  half  a  glass  of  pus  and  blood. 

This  body  was  the  size  of  a  sparrow's  egg,  pearly  in  color,  and  had  a  sebaceous 
odor.  Its  center  was  hard  and  consisted  of  a  piece  of  clay  containing  several 
particles  of  grit  and  several  hairs  of  the  same  color  as  those  of  the  patient.  He  was 
a  stone-cutter,  and  particles  had  evidently  dropped  into  the  umbilical  cavity. 

Two  Specimens  of  Umbilical  Calculi.!  — -Case  1 . — A  man, 
twenty-three  years  of  age,  had  noticed  a  discharge  from  the  umbilicus  for  eight  weeks. 
The  surrounding  abdominal  wall  was  indurated  and  tender.  Later  a  calculus  was 
extracted.  The  sinus  and  a  granuloma  which  had  formed  around  its  margins 
rapidly  disappeared.  The  concretion  was  1.5  cm.  long,  oval  in  form,  and  consisted 
of  closely  packed  squamous  epithelial  cells  with  a  certain  number  of  hairs. 

Case  2  . — A  man,  thirty  years  old,  had  had  a  discharge  from  the  umbilicus 
for  five  years,  associated  with  a  granuloma.  Around  the  sinus  was  granular  tissue 
which  formed  a  tumor  the  size  of  a  cherry.  The  sinus  was  opened  and  found  to  be 
burrowing  in  various  directions.  An  oval  concretion,  2.5  cm.  long,  was  found. 
Over  certain  areas  this  was  smooth  and  had  a  silvery  exterior.  From  the  surface 
projected  the  ends  of  fine  hairs,  and  a  section  presented  traces  of  laminations.  In 
the  center  was  a  small  piece  of  flocculent  material — cotton  fiber.  The  concretion 
consisted  of  closely  packed,  flattened,  and  wrinkled  epithelial  cells. 

Dermoid  Cyst  in  the  Abdominal  Wall  of  a  Man  [  ?  ]  .  §  — 
A  man,  twenty-two  years  of  age,  four  weeks  before  coming  under  observation  had 
noticed  a  small  mass  in  the  median  line  of  the  abdomen  directly  below  the  umbilicus. 
It  had  gradually  increased  in  size  until  it  was  as  large  as  an  egg,  hard  and  tender. 

*  Rouget:   Gaz.  des  hop.,  1862,  259. 

t  Roques:  Kyste  occasionne  par  la  presence  d'un  fragment  de  terre  dans  l'ombilic.  Gaz. 
des  hop.,  1862,  314. 

t  Shattock,  S.  G.:  Trans.  Path.  Soc.  London,  1900,  li,  282. 
§  Taylor,  Wm.  J.:  Annals  of  Surgery,  1896,  xxiii,  296. 
18 


258  THE    UMBILICUS    AND    ITS    DISEASES. 

He  had  had  some  purulent  discharge  from  the  umbilicus  before  entering  the  hos- 
pital.    This  had  increased  in  quantity. 

An  incision  was  made  over  the  swelling,  and  about  an  ounce  of  foul-smelling 
pus  was  evacuated.  The  probe  passed  from  the  umbilicus  into  the  abscess  cavity. 
At  the  bottom  of  the  cavity,  and  communicating  with  it,  was  a  depression  contain- 
ing soft,  cheesy  material  and  a  small  amount  of  hair.  Taylor  considered  the  nodule 
as  a  small  dermoid  that  had  become  infected.  It  was  limited  strictly  to  the  abdom- 
inal wall.  The  abscess  cavity  and  cyst  were  cureted  freely;  the  umbilicus  was 
dissected  away.  The  cavity  was  filled  with  iodoform  gauze.  Prompt  recovery 
ensued. 

[In  all  probability  this  was  an  abscess  due  to  retained  material.  Had  a  dermoid 
existed,  it  would  have  been  almost  impossible  to  curet  and  completely  remove  the 
cyst-wall.— T.  S.  C] 

Dermoid  Cyst  of  the  Umbilicus  [?].*■ — -A  man,  twenty-nine 
years  of  age,  had  a  tumor  the  size  of  a  walnut  at  the  umbilical  cicatrix.  This  was 
bright  red  in  color,  moist,  and  translucent.  On  the  surface  it  was  firm  in  consist- 
ence; it  did  not  pulsate,  was  irreducible,  and  had  a  short  pedicle.  The  pedicle  was 
smaller  than  the  top  of  the  umbilicus,  and  there  was  a  discharge  of  seropurulent 
fluid,  yellowish  in  color  and  of  an  offensive  odor.  The  tumor  was  dissected  out, 
but  returned  rapidly.  Histologic  examination  showed  a  membrane  of  fibrous 
tissue;  the  contents  were  cholesterin  crystals,  numerous  epithelial  cells,  and  col- 
orless hairs.     Tremontani  thought  the  tumor  was  a  dermoid. 

[It  strongly  suggests  an  accumulation  at  the  umbilicus. — T.  S.  C] 

Umbilical  Pocket. f  —  A  man,  thirty-four  years  old,  complained  of 
periodic  attacks  of  mild  stomachache  with  a  slight  discharge  from  the  umbilicus. 
The  umbilical  depression  led  to  a  skin  pocket  containing  a  yellowish  mass  which 
the  patient  said  had  been  there  for  years.  The  mass  was  readily  detached  by  care- 
ful probing,  and  proved  to  consist  of  felted  hairs  and  sebaceous  material.  The 
pocket  was  about  two  inches  in  diameter  and  three-quarters  of  an  inch  deep,  with  an 
opening  half  an  inch  in  diameter.  No  hernia  was  present.  The  man  was  of  cleanly 
habits,  accustomed  to  take  much  exercise,  and  habitually  wore  a  home-made  belt 
of  flannel,  from  which  the  hairs  were  derived. 

An  Umbilical  Concretion. J  —  One  inch  above  the  umbilicus 
there  was  a  tumor  the  size  of  a  small  egg.  Pus  escaped  from  the  umbilicus.  A 
flaxseed  poultice  was  applied.  Suddenly  a  small  amount  of  blood  and  a  concretion 
escaped.  The  wound  healed  up  at  once.  The  mass  weighed  only  four  grains, 
and  appeared  to  be  felted  together  like  a  concretion  of  ear-wax. 

The  two  cases  which  follow  are  also  in  all  probability  instances  of  abscess  due 
to  an  accumulation  of  foreign  material  at  the  umbilicus. 

An  Umbilical  Sinus.  §  ■ — ■  The  woman  was  twenty-five  years  of  age, 
married,  and  very  stout.  Two  years  before  she  had  noticed  some  discharge  from 
the  umbilicus.     Eighteen  months  before  admission  there  were  signs  of  abscess, 

*  Tremontani,  E.:   Sopra  un  caso  di  granuloma  ombellicale  da  cisti  dermoide  in  un  adulto. 
II  Morgagni ;  Giornale  Indirizzato  Al  Progresso  Delia  Medicina,  1903,  xlv,  Parte  1;  Archivio,  387. 
t  Walters,  F.  R.:  Brit,  Med.  Jour.,  1893,  i,  173. 
1  Williams,  F.  H.:  Amer.  Med.  Jour.,  St.  Louis,  1907,  xxxv,  295. 
§  Chislett,  H.  R. :  Umbilical  Sinus.     The  Clinique,  Chicago,  1905,  xxvi,  167. 


UMBILICAL    CONCRETIONS.  259 

with  pain,  swelling,  and  redness.  An  incision  was  made.  The  sinus  was  an  inch 
deep;  the  pocket  extended  to  the  peritoneum  and  contained  thick  pus.  The  ab- 
scess was  evacuated,  and  the  granulation  tissue  cureted  away.  Iodin  was  applied 
and  the  cavity  packed  wit  h  iodoform.     She  made  a  good  recovery. 

A  Sub  umbilical  Tumor.  —  Fischer*  said  he  operated  on  a  woman 
who  had  a  fistula  to  the  right  of  and  below  the  umbilicus,  near  the  linea  alba.  This 
fistula  was  deeply  seated  and  led  to  a  fixed  tumor  the  size  of  an  apple,  which  extended 
from  the  umbilicus  8  cm.  downward  and  was  5  cm.  in  breadth.  On  pressure  there 
escaped  pus  and  cheesy,  tenacious  masses  and  hair.  The  patient  had  noticed  the 
tumor  for  only  five  weeks,  and  then,  on  account  of  the  inflammation  and  swelling 
that  had  developed.  It  had  ruptured  fourteen  days  before  admission.  As  the 
tumor  was  nowhere  adherent  to  the  peritoneum,  it  was  removed  without  difficulty. 


CASES  OF  UMBILICAL  HORN. 

This  condition  is  evidently  very  rare,  as  I  could  find  records  of  only  two  cases, 
those  of  Hennig  and  Xagel.  Unfortunately,  the  data  relating  to  these  are  not  very 
clear. 

In  Hennig's  case  the  horn  was  about  2  cm.  long,  1  cm.  in  diameter,  and  slightly 
bent,  while  in  Nagel's  case  it  was  1  cm.  long.  The  consistence  is  not  mentioned  in 
either  case.     Both  dropped  off  spontaneously. 

It  is  difficult  to  understand  how  a  horny  growth  can  appear  in  this  situation. 
In  1910  I  saw  a  woman  over  ninety  years  of  age  with  a  small,  dark  mass  protruding 
from  a  very  small  umbilical  depression.  This  mass  was  black  and  hard  in  con- 
sistence. When  pressure  was  made  around  the  umbilicus  the  mass  protruded 
fully  1  cm.  from  the  level  of  the  abdomen.  Further  pressure  caused  still  more  pro- 
trusion, and  the  mass  dropped  out.  It  was  an  umbilical  concretion.  On  account 
of  the  exposure  to  the  air  the  superficial  portion  had  become  very  hard  and  was 
black,  whereas  the  part  lying  more  deeply  in  the  umbilicus  was  whitish  yellow  and 
cheesy  (see  Fig.  147,  p.  249) .  It  will  be  noted  that  the  superficial  portion  of  Xagel's 
specimen  was  also  black.  It  is  just  possible  that  in  both  of  these  cases  the  horns 
were  in  reality  hardened  umbilical  concretions  and  not  true  umbilical  horns. 

A  Case  of  Horn  of  the  Umbilicus.  —  Pernicef  says  that  Hennig 
saw  a  healthy  American  who  from  her  childhood  had  had  a  horn  at  the  umbilicus. 
It  was  about  2  cm.  long,  1  cm.  thick,  cone-shaped,  and  slightly  bent.  In  the  eighth 
month  of  her  first  pregnancy  the  horn  dropped  off,  partly  as  result  of  the  unfolding 
of  the  umbilicus,  "partly  as  a  result  of  diminished  nourishment." 

A  Small  Horn  at  the  Umbilicus.  —  In  a  letter  to  Dr.  Kelly 
Prof.  F.  W.  Nagel  mentions  the  case  of  Frau  H.,  who  was  born  in  Berlin,  Decem- 
ber, 1878.  On  the  eighth  of  June,  1907,  she  was  delivered  for  the  first  time  by 
Nagel.  About  the  middle  of  the  pregnancy  a  little  prominence,  the  thickness  of 
a  match,  was  noticed  at  the  umbilicus.  This  was  more  and  more  -visible  toward 
the  end  of  pregnancy.  It  formed  a  horn  1  cm.  long.  At  the  beginning  it  was  gray; 
later  on  it  dried  up  and  became  black.     After  labor  the  horn  drew  in  and  disap- 

*  Fischer,  H. :    Die  Eiterungen  im  subunibilicalen  Raume.     Volkmann's  Samml.  klin.  Vor- 
trage,  Neue  Folge,  Nr.  89  (Chir.  No.  24),  Leipzig,  1890-94,  519. 
f  Pernice,  L.:    Die  Nabelgeschwiilste,  Halle,  1892. 


260  THE    UMBILICUS    AND    ITS    DISEASES. 

peared.     Nagel  examined  the  patient  on  December  10,  1910,  and  by  separating  the 
umbilical  folds  was  able  to  see  the  points  of  the  now  yellowish-white  horn. 


MAGGOTS  IN  THE  UMBILICUS. 

In  a  letter  dated  December  9,  1910,  Dr.  John  S.  Fulton  gave  me  an  account  of 
a  rather  unusual  umbilical  condition.  Several  years  previously  a  baker  had  come 
to  his  clinic  at  the  University  of  Maryland  complaining  of  some  umbilical  trouble. 
Fulton  watched  the  man  undress,  and  at  once  recognized  his  occupation  by  three 
rings  of  dough — "waist  deep,  midarm  deep,  and  elbow  deep."  On  examining  the 
umbilicus  he  found  it  inhabited  by  six  maggots.  Their  removal  was  followed  by 
complete  relief  of  the  patient. 

The  only  other  case  I  know  of  in  which  a  similar  condition  was  noted  was 
furnished  by  E.  L.  M.*  in  1899.  He  was  called  to  see  an  infant  eight  days  old.  The 
cord  had  come  off  on  the  fifth  day.  On  examination  the  umbilicus  was  found  filled 
with  maggots.  A  few  drops  of  chloroform  were  dropped  into  the  umbilicus,  and 
24  dead  maggots  were  washed  out  with  sterilized  water.  Boric  acid  was  then 
dusted  in  and  there  was  no  further  trouble. 

Escape  of  a  Piece  of  Wild-oat  Straw  From  an  Umbil- 
icus, t  —  The  patient  was  one  month  old.  The  mother  had  noticed  much 
moisture  at  the  umbilicus  ever  since  the  cord  had  come  away.  At  the  umbilicus 
was  a  reddish,  pedunculated  tumor  the  size  of  a  pea.  This  was  cut  away  with 
scissors  and  cauterized.  It  recurred,  but  on  being  again  treated  in  a  similar  manner, 
did  not  reappear.  Some  time  later  an  abscess  developed  at  the  umbilicus.  It  was 
opened,  some  pus  and  a  piece  of  wild-oat  straw  escaping.  The  fact  that  there  was 
continual  moisture  at  the  umbilicus  after  the  cord  came  away  strongly  suggested 
a  remnant  of  either  the  omphalomesenteric  duct  or  the  urachus. 

*  E.  L.  M. :  Maggots  in  the  Umbilicus.     Med.  Council,  Philadelphia,  1899,  iv,  364. 
f  Fabrege:    Note  sur  les  excroissances  polypeuses  de  la  fosse  ombilicale  chez  les  enfants 
nouveau-nes.     Rev.  med.  chir.,  1848,  iv,  353. 


LITERATURE  CONSULTED  ON  UMBILICAL  CONCRETIONS  ASSOCIATED  WITH 

INFLAMMATORY  CHANGES  IN  THE  ABDOMINAL  WALL. 

Blum,  A.:   Tumeurs  de  l'ombilic  chez  l'adulte.     Arch.  gen.  de  med.,  Paris,  1876,  6e  ser.,  xxxviii, 

151. 
Bouffleur:  Tuberculosis  of  the  Umbilicus.     Clin.  Review,  Chicago,  1898,  ix,  329. 
Bufalini,  G.:  Jahresber.  der  gesammt.  Med.,  1887,  ii,  497. 

Coenen,  H. :  Ueber  das  Cholesteatom  des  Nabels.     Beitrage  z.  klin.  Chir.,  1908,  lviii,  71S. 
Cbislett,  H.  R. :  The  Clinique,  Chicago,  1905,  xxvi,  167. 

Derville,  L. :  Abces  fistuleux  de  l'ombilic.     Jour,  des  sci.  med.  de  Lille,  1894,  ii,  320. 
Fere,  G.:  Tumeur  sebacee  ombilicale.     Bull.  Soc.  anat.  de  Paris,  1875, 1,  622. 
Fischer,  H.:   Volkmann's  Sammlung  klin.  Vortrage,  Neue  Folge,  Nr.  89  (Chirurg.,  Xo.  24), 

Leipzig,  1890-94,  519. 
Foulerton,  A.'G.  R. :  Form  of  Umbilical  Sinus  Occurring  in  Adults.     The  Lancet,  1888,  ii,  16. 
Foulerton,  A.  G.  R. :  Growths  From  the  Umbilicus.     Illustrated  Medical  News,  1889,  iv,  261. 
Gonard,  G.:   Des  kystes  dermo'ides.     These  de  Montpellier,  1906,  No.  31. 
Gueterbock,  P. :  Ueber  einen  Fall  von  Dermoidgeschwulst  des  Nabels.     Deutsche  Zeitschr.  f. 

Chir.,  1891,  xxxii,  319. 


UMBILICAL   CONCRETIONS.  261 

Hahn,  Otto:    Ein  Nabelkonkrement  von  Taubeneigros.se.     Beitrage  z.  klin.  Chir.,  Tubingen, 

1900,  xxvi,  80. 
Ledderhose,  G. :   Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Nicaise:  Ombilic.     Dictionnaire  encyclopedique  des  sci.  m6cl.,  Paris,  1881,  2.  ser.,  xv,  140. 
Park,  Roswell:    Clinical  Lecture  on  Congenital  Fistulso  and  Sinuses  at  the  Umbilicus.     Med. 

Fortnightly,  1896,  ix,  9. 
Pernice,  L. :   Die  Nabclgcschwulstc,  Halle,  1892. 

Polaillon:   Kyste  dcrmoide  suppure  de  la  region  ombilicale.     Gaz.  med.  de  Paris,  1886,  lvii,  435. 
Richelot,  L.  G. :  Abces  tuberculeux  sous-ombilical.     L'union  m6d.,  1883,  xxxv,  61. 
Rouget:  Gaz.  des  hop.,  1862,  259. 
Rouqes:   Kyste  occasionne  par  la  presence  d'un  fragment  de  terre  dans  l'ombilic.     Gaz.  des  hop., 

1862,  314. 
Shattock,  S.  G. :  Two  Specimens  of  Umbilical  Calculi.     Trans.  Path.  Soc.  London,  1900,  li,  282. 
Taylor,  Wm.  J. :   Dermoid  Cyst  in  the  Abdominal  Wall  of  a  Man.     Annals  of  Surgery,  1896,  xxiii, 

296. 
Tremontani,  E.:   Spora  un  caso  di  granuloma  ombellicale  da  cisti  dermoide  in  un  adulto.    II  Mor- 

gagni;  Giornale  Indirizzato  al  Progresso  della  Medicina,  Parte  1,  Archiv,  1903,  45,  387. 
Villar,  F.:  Tumeurs  de  l'ombilic.     These  de  Paris,  1886,  No.  19. 
Walters,  F.  R. :  Umbilical  Pocket.     Brit.  Med.  Jour.,  1893,  i,  173. 
Williams,  F.  H.:  An  Umbilical  Concretion.     Amer.  Med.  Jour.,  St.  Louis,  1907,  xxxv,  295. 


CHAPTER  XVI. 
ABSCESS  IN  THE  SUBUMBILICAL  SPACE. 

Description  of  Heurtaux's  observations. 

Fischer's  injections  of  the  subumbilical  space. 

An  empyema  opening  into  the  subumbihcal  space. 

A  liver  abscess  opening  into  the  subumbilical  space. 

An  appendix  abscess  opening  into  the  subumbilical  space. 

An  echinococcus  cyst  in  the  subumbilical  space. 

Actinomycosis  in  the  subumbilical  space. 

Resume. 


Heuktaux,*  in  1877,  described  what  he  called  a  phlegmonous  subumbilical 
inflammation  deep  in  the  anterior  abdominal  wall.  He  said  that,  up  to  that  time, 
so  far  as  he  knew,  this  condition  had  never  been  reported.  The  affection  is  charac- 
terized by  the  presence  of  an  inflammatory  tumor,  which  is  sharply  circumscribed 
and  is  in  the  median  line.  It  is  symmetric  and  oval  inform;  its  base  occupies  the 
umbilicus.     The  tumor  is  deep-seated.     On  examination  it  will  be  found  to  have 

developed  exactly  at  the  umbilicus  (Fig.  153) .  It  varies 
from  6  to  10  cm.  in  diameter,  is  immobile,  firm  in  con- 
sistence, and  after  a  few  days  may  give  deep  fluctuation. 
When  suppuration  commences,  the  tumor  becomes 
prominent  and  the  umbilicus  may  be  reddened  and  per- 
forate, the  quantity  of  escaping  pus  varying  from  120  to 
150  c.c.  In  Heurtaux'  cases  there  never  was  any  escape 
of  gas.  A  sound  sometimes  entered  toward  the  pubes 
for  6  cm.,  and  to  the  right  or  left  for  3  cm.  In  three 
acute  cases,  fluctuation  was  detected  in  from  nine  to 
seventeen  days  after  the  onset ;  in  subacute  cases,  after 
a  period  varying  from  four  to  five  weeks. 

In  all  of  the  six  cases  reported  by  Heurtaux  the 
phlegmon  terminated  in  suppuration.  In  four  it  opened 
spontaneously,  the  opening  being  in  the  umbilical  cica- 
trix in  two  of  these.  According  to  Heurtaux,  the  lesion 
is  always  found  in  the  same  situation  and  the  prognosis 
is  good. 

An  analysis  of  Heurtaux'  cases  shows  that  the 
youngest  patient  was  six  and  one-half  years,  the  oldest,  fifty-five.  Nearly  all  of 
them  had  been  ill  before.  Three  were  males  and  three  females.  In  Case  2  a  labor 
had  occurred  three  weeks  before  the  abscess  developed;  in  Case  3  it  followed  a 
pleurisy;  in  Case  6  it  developed  in  the  course  of  measles,  and  a  severe  broncho- 
pneumonia also  complicated  matters.     In  Case  1  the  patient  was  in  the  second 

*  Heurtaux,  A.:    Phlegmon  sous-ombilical.     Bull,  et  Mem.  de  la  Soc.  de  chir.  de  Paris, 
n.  s.,  1877,  iii,  641. 

262 


Fig.  153. — Subumbilical  Phleg- 
mon-. (After  Heurtaux.) 
According  to  Heurtaux,  the 
swelling  is  sometimes  visible  with 
the  naked  eye,  and  appears  as  an 
oval  tumefaction,  slightly  promi- 
nent, and  shading  off  into  the  sur- 
rounding tissue. 


ABSCESS    IN    THE    SUBUMBILICAL    SPACE.  263 

stages  of  syphilis,  and  in  Case  4  the  patient  had  recovered  from  a  grave  attack  of 
typhoid  fever.  In  four  of  the  cases  the  symptoms  were  acute;  in  two,  subacute. 
In  the  acute  cases  there  were  severe  pain,  sensitiveness  in  the  umbilical  region, 
and  a  tendency  toward  constipation.     In  some  cases  there  was  vomiting. 

The  observations  of  Heurtaux  seem  in  a  large  measure  to  have  been  overlooked, 
and  it  was  not  until  the  work  of  Fischer*  that  we  again  hear  much  on  this  subject. 
Fischer  wrote  a  most  extensive  article  in  which  he  discussed  acute  subumbilical 
phlegmon,  chronic  abscess  in  the  subumbilical  space,  and  the  breaking  through  of 
purulent  collections  into  the  subumbilical  space.  In  the  beginning  he  refers  to  the 
work  of  Heurtaux,  and  says  that  Jolion  and  Heurtaux  in  1877  studied  the  anatomy 
and  pathology  of  the  subumbilical  region  and  found  on  each  side  of  the  linea  alba 
a  triangular  space.  He  says  that  Charpy,  in  1888,  found  that  the  subumbilical 
space  was  in  part  retroperitoneal,  in  part  prefascial. 

Fischer  tried  to  fill  the  subumbilical  space  by  injecting  colored  gelatin  with  a 
syringe  introduced  through  an  incision  in  the  lateral  wall  of  the  rectus,  the  needle 
being  directed  inward  and  between  the  sheath  of  the  rectus  and  the  peritoneum. 
By  this  procedure  he  was  able  to  produce  a  tumor,  heart-shaped  in  form,  with  its 
base  at  the  umbilicus  and  the  apex  about  6  cm.  below  it  (Fig.  154).  It  was  most 
prominent  laterally,  and  diminished  toward  the  linea  alba,  where  it  was  repre- 
sented by  a  fine  furrow.  At  its  base  it  was  14.6  cm.  broad;  at  its  apex,  1.6  cm.; 
its  greatest  length  was  from  8  to  9  cm.  In  men  and  women,  in  young  and  old,  in 
fat  and  thin,  the  space  was  always  the  same  size.  Above  it  was  closed  partly  by 
the  umbilical  scar,  partly  by  firm  adhesions  between  the  peritoneum  and  the  sheath 
of  the  rectus,  at  the  outer  side  and  below  only  by  adhesions  between  the  peritoneum 
and  the  sheath  of  the  rectus.  Jouon  said  that  there  was  no  definite  walling-off 
below,  but  that  a  loose  connective  tissue  existed  through  which  the  space  communi- 
cated with  the  cavity  of  Retzius. 

On  page  523  Fischer  says  that  suppurations  which  start  in  the  subumbilical 
space  run  either  an  acute  or  a  chronic  course,  and  whereas  some  develop  in  the 
space,  others  wander  in.     He  then  goes  on  to  describe  briefly  the  clinical  picture. 

In  speaking  of  acute  subumbilical  phlegmon,  he  says  that  he  had  five  defi- 
nite cases  of  subumbilical  inflammation,  such  as  were  described  by  Heurtaux,  and 
that  in  all  he  found  the  same  characteristic  picture.  Fischer's  tumors  developed 
in  men  from  seventeen  to  thirty-four  years  of  age,  who,  apart  from  a  gonococcal 
infection,  had  always  been  well.  None  of  them  had  had  a  definite  trauma  nor  was 
there  any  evidence  of  such  a  condition  having  existed. 

The  affection  commences  with  a  chill,  and  there  is  fever  during  the  entire  course 
of  the  disease,  the  temperature  varying  from  38.5°  to  39.5°  C.  There  is  marked 
pain  on  attempting  to  straighten  out  the  legs  and  on  pressure  on  the  abdomen. 
The  pain  commences  at  the  umbilicus  and  spreads  in  all  directions.  The  patient 
accordingly  lies  perfectly  flat  on  the  back,  with  the  legs  drawn  up  and  the  abdomen 
tense.  In  addition  there  is  constant  vomiting  of  slimy,  pale-stained  masses,  the 
effort  naturally  increasing  the  amount  of  abdominal  pain.  The  vomiting  increases, 
and  there  is  a  feeling  of  faintness.  The  patient  becomes  pale  and  shows  signs  of 
collapse.  The  extremities,  however,  remain  warm.  The  pulse  is  quick  and  the 
expression  anxious.     These  symptoms  are  so  pronounced  at  times  that  peritonitis 

*  Fischer,  H.:  Die  Eiterungen  im  subumbilicalen  Raume.  Volkmann's  Samml.  klin.  Vor- 
trage,  n.  F.,  No.  89  (Chir.  No.  24),  Leipzig,  1890-94,  519. 


264 


THE    UMBILICUS    AND    ITS    DISEASES. 


is  thought  of  and  a  bad  prognosis  is  given.  Nevertheless,  after  the  distressing 
symptoms  have  lasted  two  to  four  days  the  vomiting  disappears.  The  bowels 
move  again  and  flatus  is  expelled.  The  pain  becomes  more  marked  in  the 
umbilical  region,  and  a  faint  reddening  and  edema  are  noted  in  this  situation.  On 
palpation  one  can  now  feel  a  dense  but  movable  infiltration,  triangular  in  form, 


Fig.  154. — The  Subumbilical  Space.  (Schematic.) 
Heurtaux  has  described  a  series  of  cases  in  which  abscesses  have  developed  just  below  the  umbilicus.  He  speaks 
of  these  as  subumbilical  abscesses.  Fischer  has  attempted  to  outline  these  spaces  by  using  injections  of  gelatin.  This 
sketch  has  been  drawn  after  the  description  and  measurements  of  Fischer.  The  umbilicus  is  seen  in  the  midline.  On 
each  side  of  this  the  fascia  and  muscle  have  been  removed.  The  space  is  situated  just  below  the  umbilicus,  and  lies 
behind  the  rectus  muscles.  The  base  of  the  space  is  indicated  by  a  line  drawn  between  o  and  b.  The  apex  of  the 
space  is  at  c  and  d.  The  space  is  usually  partially  or  completely  divided  by  a  septum  which  extends  from  the  umbilicus 
above  to  the  apex  below.  The  anterior  wall  of  the  space  is  composed  of  the  sheath  of  the  rectus,  its  posterior  wall, 
of  peritoneum.  The  distance  between  a  and  b  averages  14.6  cm.  The  distance  between  the  umbilicus  and  c  averages 
8  or  9  cm.     The  distance  between  c  and  d  averages  1.6  cm. 


limited  by  the  outer  walls  of  the  recti,  and  with  its  base  directed  upward.  The 
skin  can  be  pushed  over,  but  is  not  gathered  up  into  folds.  There  is  dulness  on 
percussion. 

In  the  course  of  from  nine  to  twelve  days,  with  the  gradual  disappearance  of 
the  general  disturbances,  there  develops  on  both  sides  of  the  linea  alba  a  firm,  elastic 
tumor  below  the  umbilicus.     This,  as  was  pointed  out  by  Heurtaux,  is  of  the  size 


ABSCESS    IN    THE    SUBUMBILICAL    SPACE.  265 

and  form  of  the  urinary  bladder.  Not  infrequently  a  definite  long  furrow  can  be 
traced  downward  from  the  umbilicus.  This  is  the  linea  alba,  which  partially  or 
completely  divides  this  space  into  two  parts.  Finally,  this  tumor  rises  5  or  6  cm. 
above  the  level  of  the  abdominal  wall.  Under  chloroform  narcosis  the  recti 
muscles  can  be  pushed  over  the  tumor.  The  fluctuation  becomes  more  and  more 
evident.  Fischer,  contrary  to  the  observations  of  others,  has  never  noted  spon- 
taneous rupture  either  outward  or  into  the  peritoneal  cavity. 

Fischer  says  that  in  four  of  the  cases,  after  making  the  incision,  he  found  that 
he  was  dealing  with  a  single  abscess  cavity,  although  there  are  two  subumbilical 
spaces  separated  from  each  other  by  the  linea  alba.  It  could  very  readily  happen 
he  decides,  that  in  these  cases  one  portion  of  the  cavity  might  be  infected  and  the 
inflammation  extend  to  the  opposite  side.  Fischer,  in  one  case,  was  able  to  carry 
his  finger  from  the  first  cavity  over  to  the  second  through  an  opening,  a  dividing 
partition  still  persisting. 

Differential  Diagnosis.  —  The  differential  diagnosis  in  this  group 
of  cases  is  not  always  perfectly  clear.  Fischer  mentions  the  fact  that  in  two  cases 
he  found  flat  epithelial  cells  in  the  pus  contents.  Their  presence  would  be  against 
the  existence  of  a  subumbilical  abscess.  Where  flat  epithelial  cells  are  found  in 
such  an  abscess  the  inflammatory  process  is  usually  of  urachal  origin.  This  group 
is  a  very  characteristic  one,  and  is  described  on  page  567. 


ABSCESSES  BREAKING  THROUGH  INTO  THE  SUBUMBILICAL  SPACE. 

Fischer,  after  describing  the  subumbilical  space,  records  three  cases  in  which  a 

purulent  accumulation  from  distant  points  found  its  way  into  the  subumbilical 

space.     One  was  an  empyema,  another  a  liver  abscess,  and  the  third  an  appendix 

abscess.     In  each  of  these  cases  the  subumbilical  space  was  involved  secondarily. 

An  Empyema  Opening  into  the  Subumbilical  Space. 

Fischer,  on  page  535,  mentions  the  case  of  a  Russian  girl,  eight  years  of  age,  who 
had  a  left-sided  empyema  which  reached  as  high  as  the  scapula.  In  addition  there 
was  a  fluctuating,  egg-shaped  tumor  below  the  umbilicus,  and  to  the  left  of  the  linea 
alba.  When  the  patient  coughed,  this  swelling  increased  in  size  at  the  subumbilical 
space.  Fischer  resected  several  ribs  and  found  that  water  would  flow  through  the 
entire  space  as  far  as  the  umbilicus.  The  child  finally  recovered.  In  this  case 
there  was  a  fistulous  opening  from  the  pleural  cavity  downward  to  the  subumbilical 
space. 

A  Liver  Abscess  Opening  into  the  Subumbilical  Space. 

Fischer  and  Biermer,  in  1876,  treated  a  patient  suffering  from  liver  abscess, 
which,  however,  gave  no  characteristic  symptoms.  The  patient  was  twenty-seven 
years  of  age.  There  was  a  history  of  injury,  followed  some  time  later  by  an  irregular 
fever.  The  liver  dulness  was  increased.  Six  months  after  the  injury,  when  Fischer 
saw  the  patient,  there  was  an  oval  tumor  to  the  right  of  and  below  the  umbilicus, 
with  the  base  directed  upward  and  the  apex  downward.  The  tumor  was  soft  and 
fluctuating  and  increased  in  size  when  the  patient  coughed.  On  pressure  it  could 
be  made  smaller.  It  was  8  cm.  in  length  and  9  cm.  in  its  greatest  breadth.  It  was 
incised,  and  there  escaped  a  yellowish-tinged,  foul-smelling  pus  in  which  liver  sub- 
stance could  be  detected.    The  abscess  cavity  had  the  size  and  form  of  a  subumbilical 


266  THE    UMBILICUS    AND    ITS    DISEASES. 

space.  As  the  fever  persisted  Fischer  made  an  incision  parallel  to  the  margins  of 
the  ribs,  and  opened  into  a  large  retroperitoneal  abscess  which  had  been  shut  off  on 
all  sides.  From  this  an  opening  extended  downward  into  the  subumbilical  space. 
The  patient  improved  slowly  and  gradually  recovered. 

An  Appendix  Abscess  Opening  into  the  Subumbilical  Space. 
Fischer  says  that  an  appendix  abscess  occasionally  opens  into  the  subumbilical 
space.  On  page  536  he  reports  the  case  of  a  woman,  twenty-seven  years  of  age, 
who  came  to  the  Breslau  clinic  on  account  of  a  fecal  fistula  below  and  to  the  right 
of  the  umbilicus.  Ten  months  previously  she  had  had  severe  abdominal  pain, 
vomiting,  and  obstruction.  After  six  weeks  of  much  suffering  an  egg-shaped  tumor 
had  developed  and  a  fistula  had  followed.  First  there  had  escaped  foul-smelling 
pus  and  then  fecal  matter.  On  splitting  the  abdominal  walls  Fischer  noticed  a 
cavity  lined  with  granulations.  The  abscess  in  position,  form,  and  size  corre- 
sponded exactly  with  the  subumbilical  space.  In  its  posterior  wall  in  the  lower  and 
outer  angle  was  a  fecal  fistula  which  had  arisen  from  an  ulcerated  vermiform  appen- 
dix. In  its  lumen  was  a  cherry-stone.  After  removal  of  the  stone,  resection  of  the 
appendix,  and  cureting  of  the  abscess  cavity,  healing  took  place. 


AN  ECHINOCOCCUS  CYST  IN  THE  SUBUMBILICAL  SPACE. 
This  condition  is  evidently  rare,  as  I  have  found  but  one  case  recorded.  Fischer 
said  that  he  operated  on  a  man,  thirty-two  years  of  age,  in  whom  a  fluctuating, 
smooth,  painless,  immovable  tumor,  the  size  of  a  fist,  had  developed  beneath  and 
to  right  of  the  umbilicus,  near  the  median  line.  It  had  been  noted  for  six  years. 
The  patient  during  this  time  had  often  vomited,  but  otherwise  had  been  healthy. 
For  three  weeks  the  tumor  had  been  painful  and  increasing  in  size.  Fever  had 
been  present,  and  the  skin  had  become  reddened  and  edematous.  In  size,  form, 
and  position  the  tumor  corresponded  with  the  subumbilical  space.  Fischer  made 
an  incision  at  the  outer  wall  of  the  rectus  and  into  the  subumbilical  space.  There 
was  a  densely  adherent  echinococcus  sac,  which  could  not  be  extirpated  on  account 
of  firm  adhesions  binding  it  to  the  peritoneum.  It  was  split,  scraped  out,  and 
packed.     The  patient  made  a  good  recovery  and  remained  apparently  well. 


ACTINOMYCOSIS  IN  THE  SUBUMBILICAL  SPACE. 
Fischer  furnishes  the  only  record  of  such  a  case  that  I  am  familiar  with.  The 
patient  was  a  man  in  whom  an  actinomycotic  infiltration  was  noted  as  a  firm,  cir- 
cumscribed tumor  the  size  of  an  apple  in  the  subumbilical  space.  It  gave  the 
patient  little  discomfort.  The  skin  was  movable  over  the  tumor  and  was  not 
altered.  At  first  there  was  no  fever.  Later,  at  intervals,  there  appeared  an 
inflammatory  but  painless  swelling.  Four  months  after  the  patient  first  noticed 
his  trouble,  edema  developed,  and  there  were  thickening  and  reddening  over  the 
tumor,  which  broke  through  the  skin  at  several  points.  The  escaping  pus  contained 
a  few  actinomycotic  bodies.  On  the  third  day  feces  escaped.  The  fistulse  lay  below 
the  umbilicus,  one  on  each  side  of  the  linea  alba,  and  communicated  with  each 
other.     In  attempting  an  extirpation  and  clearing-out  of  the  sinuses,  Fischer  found  a 


ABSCESS    IN    THE    SUBUMBILICAL    SPACE.  267 

sieve-like  fistula  representing  the  points  at  which  the  intestine  had  broken  through. 
The  patient  died  fourteen  days  after  the  operation. 

Resume.  — ■  From  the  foregoing  it  is  clearly  evident  that  below  the  umbilicus 
there  is  a  definite,  heart-shaped  cavity — the  subumbilical  space — about  8  cm.  in 
length  and  14  cm.  broad.  This  is  situated  between  the  peritoneum  and  the  sheaths 
of  the  muscles.  It  is  often  divided  longitudinally  into  two  cavities  by  the  linea  alba, 
which  forms  a  septum  between  the  muscle-sheath  in  front  and  the  peritoneum 
behind.     This  subperitoneal  space  can  be  definitely  outlined  by  injection  methods. 

There  is  no  doubt  that  subumbilical  abscesses  can  develop.  The  symptoms  in 
the  early  stages  strongly  suggest  a  peritonitis;  later  the  general  abdominal  symp- 
toms subside,  and  a  localized  tumor  can  be  detected  just  below  the  umbilicus. 
When  opened,  the  abscess  is  found  to  lie  between  the  muscle-sheath  and  the  peri- 
toneum. Usually  the  septum  between  the  two  sacs  disappears,  leaving  only  one 
abscess  cavity. 

Whether  all  the  hitherto  reported  cases  were  really  abscesses  in  the  subumbilical 
spaces  or  not  is  problematical.  Those  cases  in  which  epithelial  elements  were 
detected  probably  represented  abscesses  resulting  from  infection  of  remnants  of  the 
urachus. 

That  the  subumbilical  space  may  be  secondarily  involved  seems  to  be  clearly 
shown  by  the  cases  of  empyema  and  liver  abscess  reported  by  Fischer.  The  possi- 
ble presence  of  echinococcus  cysts  and  actinomycosis  in  the  subumbilical  space 
is  proved  by  the  cases  above  described. 

Treatment.—  As  soon  as  these  abscesses  are  diagnosed,  they  should  be 
opened  and  drained.  Not  much  force  should  be  used  in  the  packing,  as  the  posterior 
wall  of  the  abscess  consists  merely  of  the  thickened  peritoneum.  Recovery 
promptly  follows  evacuation  of  the  pus. 


CHAPTER  XVII. 
PAGET'S  DISEASE  OF  THE  UMBILICUS. 

Fox  and  MacLeod's  case. 

Milligan's  case. 

The  results  with  radium  in  a  case  of  Paget's  disease  of  the  umbilicus. 

Eczema  of  the  umbilicus. 

The  first  case  of  this  character  found  in  the  literature  is  that  recorded  by  Fox 
and  MacLeod  and  published  in  1904.  In  1911,  W.  A.  Milligan  reported  a  case. 
As  the  condition  is  very  rare,  these  cases  will  be  cited  here  somewhat  in  detail. 

A  Case  of  Paget's  Disease  of  the  Umbilicus.*  —  The 
patient  under  consideration  appeared  before  the  Dermatological  Society  of  London 
on  November  13,  1901,  and  a  microscopic  section  of  a  portion  of  the  diseased  tissue 
was  demonstrated.  At  the  meeting  of  the  society  on  March  12,  1902,  further  micro- 
scopic specimens  were  exhibited,  confirming  the  diagnosis  of  Paget's  disease.  The 
following  detailed  account  is  given  by  Fox  and  MacLeod : 

"  The  patient,  a  seafaring  man  of  sixty-five  years,  came  under  the  care  of  Mr.  W. 
Turner,  surgeon  to  the  Dreadnought  Hospital  at  Greenwich,  and  assistant  surgeon 
to  the  Westminster  Hospital.  The  man  possessed  a  good  constitution,  and  there 
was  nothing  of  moment  to  note  in  his  personal  history,  and  no  family  historj-  of 
cancer.  In  the  umbilical  region  was  a  rounded,  eczematoid  patch  of  about  two 
inches  diameter  [Fig.  155]  which  had  gradually  been  forming  for  about  eleven 
years,  but  the  applicant  had  not  been  much  bothered  by  it,  and  exact  details  as  to 
the  history  of  the  patch  were  not  forthcoming.  The  central  part  of  the  patch  was 
of  a  brilliant  red  color,  exulcerated,  and  exuding  serum,  but  silvered  over  in  spots 
with  epithelium.  This  raw  center  passed  peripherally  into  a  well-marked,  raised, 
smooth,  broad  border,  which  terminated  abruptly,  and  over  which  the  cuticle 
was  intact.     The  whole  of  the  patch  felt  considerably  infiltrated. 

"Mr.  Turner  was  struck  by  the  objective  features  of  the  patch,  and  by  its 
chronicity  and  steady  eccentric  progression.  The  man  was  under  treatment  for  a 
considerable  time,  and  as  the  patch  proved  quite  intractable  to  all  treatment  tried 
short  of  destruction  or  removal,  Mr.  Turner  very  kindly  brought  the  patient  to  the 
Skin  Department  of  the  Westminster  Hospital,  with  the  suggestion  that  the  case 
was  one  of  Paget's  disease.  Histologic  examination  after  a  biopsy  confirmed  the 
diagnosis,  and  thereupon  Mr.  Turner  removed  the  diseased  skin,  and  was  kind 
enough  to  hand  it  to  us  for  investigation  and  to  allow  us  to  record  the  case. 

"Histologic  Changes  Present  in  the  Case. — As  the  whole 
of  the  diseased  patch  was  excised,  an  abundance  of  material  was  obtained  for  pur- 
poses of  histologic  examination.  A  quadrant  of  the  excised  tissue  was  cut  out,  and 
from  this,  longitudinal  sections  were  made.  As  a  reference  to  the  above  clinical 
description  will  show,  the  patch  was  roughly  circular  and  had  a  clearly  defined 

*  Fox  and  MacLeod:  Brit.  Jour.  Dermatol.,  1904,  xvi,  41. 
268 


paget's  disease  of  the  umbilicus.  269 

raised  border  and  an  excoriated  central  portion.  The  sections  of  the  quadrant  thus 
included  the  border  and  the  healthy  tissue  outside  it  and  a  portion  of  the  central 
excoriated  area.  These  sections  were  about  an  inch  in  length.  The  tissue  was 
fixed  and  hardened  in  alcohol,  embedded,  and  cut  in  paraffin,  and  the  sections  were 
stained  with  various  dyes,  such  as  borax-methylene-blue,  polychrome-methylene- 
blue,  safranin,  and  water-blue,  to  demonstrate  the  finer  structure  of  the  cells  of 
the  epidermis,  the  pseudococcidia,  and  the  cellular  and  fibrous  elements  of  the 
corium. 

"  1.  Changes  in  the  Epidermis. — With  the  low  power  the  epidermis  of  the  outer 
extremity  of  the  section  showed  a  slight  proliferation  in  a  downward  direction  by  a 
regular  elongation  and  widening  of  the  interpapillary  processes  and  a  rounding  of 
their  extremities.  This  proliferation  became  very  much  more  pronounced  in  the 
middle  third  of  the  section,  which  corresponded  to  the  raised  edge.  Here  the 
processes  had  become  twice  the  length  of  those  in  the  outer  third,  and  were  far  more 
irregular  in  their  shape  and  width.  Some  were  clubbed  at  the  extremities,  others 
broad  and  rounded,  and  a  few  were  conic  and  tapered.  Here  and  there,  owing  to 
the  obliquity  of  the  section  of  the  ridge-net  system,  the  familiar  appearance  of 
irregular  islands  of  the  corium  situated  in  the  epidermis  was  produced.  But  in 
spite  of  the  irregularity  in  shape  and  size  of  these  interpapillary  processes,  they  all 
ended  at  about  the  same  level  in  the  corium,  and  did  not  spread  down  irregularly 
into  it  as  in  condyloma  and  epithelioma.  In  the  outer  two-thirds  of  the  section  the 
epidermis  had  an  imperfect  stratum  corneum,  which  showed  a  tendency  to  des- 
quamate and  was  unusually  thin.  Here  and  there  it  extended  down  in  small  plugs 
or  formed  concentric  horny  pearls  where  a  depression  existed  on  the  surface.  The 
basal  layer  was  present  in  this  situation,  and  although  it  was  not  perfectly  regular, 
still  it  remained  unbroken.  The  epidermis  did  not  stain  regularly,  and  the  lower 
ends  of  the  processes  especially  stained  faintly  as  if  they  were  edematous.  Irregular 
spaces  were  present  in  the  Malpighian  layer,  but  the  interepithelial  lymphatics 
were  not  uniformly  distended  with  edematous  fluid  as  they  are  in  psoriasis  and 
eczema.  Another  peculiar  feature  of  the  epidermis  noticeable  with  the  low  power 
was  the  presence  in  it  of  a  number  of  darkly  stained,  more  or  less  rounded  bodies, 
some  of  which  were  several  times  larger  than  a  prickle-cell.  These  were  irregularly 
distributed  in  the  epidermis,  some  being  situated  superficially  near  the  horny  layer, 
others  deep  down  toward  the  basal  layer,  but  the  majority  being  in  about  the  middle 
of  the  epidermis.  These  were  arranged  singly  or  in  clusters,  and  occasionally  they 
were  grouped  together  in  a  concentric  manner,  forming  variously  shaped  figures. 
They  were  situated  among  the  prickle-cells,  and  only  a  few  of  them  could  be  detected 
at  the  edges  or  lying  free  in  the  irregular  spaces  already  referred  to.  These  rounded 
structures  are  the  "cocciclia"  of  Darier  and  Wickham. 

"Toward  the  middle  of  the  section  the  ordinary  epidermis  stopped  abruptly, 
and  was  replaced  by  a  single  layer  of  columnar  epithelium,  which  extended  over 
the  surface  and  dipped  down  at  intervals  to  form  a  lining  for  a  number  of  glands 
similar  in  appearance  to  Lieberkuhn's  follicles  of  the  small  intestine.  These  follicles 
extended  down  into  the  underlying  fibrous  stroma,  and  some  of  them  reached  to  a 
lower  level  than  the  longest  interpapillary  process.  This  showed  that  in  this  case 
a  portion  of  Meckel's  diverticulum  had  been  included  in  the  umbilicus,  an  occurrence 
which  occasionally  takes  place.  A  reference  to  [Fig.  156]  will  serve  to  show  the 
general  appearance  of  the  section  as  seen  under  a  low  power.     Only  a  portion  (about 


270 


THE    UMBILICUS    AND    ITS    DISEASES. 


three-fifths)  of  the  section  is  there  depicted,  the  outer  fifth  and  inner  fifth  bein^ 
left  out  in  the  drawing. 


Fig.  155. — Paget's  Disease  of  the  Umbilicus.     (After  Fox  and  MacLeod.) 
The  umbilicus  as  such  is  not  recognizable,  but  its  site  presents  a  somewhat  worm-eaten  appearance.    For  the  histologic 

picture  see  Figs.  156  and  157. 


Fig.  156. — Paget's  Disease  of  the  Umbilicus.  Histologic  Appearaxces  ix  Fig.  155.  (After  Fox  and  MacLeod.) 
Drawing  of  the  central  three-fifths  of  one  of  the  longitudinal  sections  referred  to  in  the  text.  It  shows  the  raised 
border  and  the  central  mucous  portion,  a,  a.  Imperfect  stratum  corneum;  b,  proliferating  epidermis;  c,  small  corni- 
fied  cell-nest;  e,  columnar  epithelium  lining  the  surface,  the  remains  of  Meckel's  diverticulum;  /,  tubular  glands  lined 
with  columnar  epithelium:  g,  dense  infiltration,  consisting  chiefly  of  plasma-cells;  h,  dilated  blood-vessel.  [This  has 
been  reduced  so  much  in  size  that  the  finer  details  are  lacking. — T.  S.  C] 


"  With  the  high  power  (Oc.  iv,  Obj.  TV,  Oil  imm.,  Leitz)  the  explanation  of  the 
peculiar  changes  in  the  epidermal  cells  already  referred  to  was  apparent.  Even  at 
the  outer  margin  of  the  section,  but  far  more  marked  toward  the  center,  the  prickle- 


paget's  disease  of  the  umbilicus.  271 

cells  at  the  lower  parts  of  the  interpapillary  processes  were  found  to  be  swollen, 
their  protoplasm  faintly  stained,  and  their  nuclei  frequently  situated  in  spaces 
within  the  cells.  The  cells  were  evidently  edematous,  and  though  toward  the 
surface  they  stained  more  naturally,  yet  the  edema  was  still  present  sufficiently 
to  interfere  with  the  process  of  cornification,  and  there  were  scarcely  any  cells  in 
the  position  of  the  granular  layer  in  which  even  a  trace  of  keratohyalin  could  be 
detected.  The  stratum  lucidum  was  also  absent,  and  the  horny  layer  was  unusually 
thin  and  tended  to  desquamate.  The  cornification  thus  took  place  without  the 
formation  of  keratohyalin,  as  it  does  in  the  red  portion  of  the  lips  [Fig.  157].  In 
spite  of  the  edema  of  the  cells,  however,  a  number  of  nuclei  in  the  process  of 


a 


Fig.  157. — Paget's  Disease  op  the  Umbilicus.  (After  Fox  and  MacLeod.) 
Drawing  of  a  portion  of  the  epidermis  with  the  raised  border  of  the  umbilical  growth  seen  in  Fig.  155.  a.  Prickle- 
cells;  b,  edematous  cell,  partially  cornified  and  globular,  prickles  lost,  protoplasm  homogeneous,  granular  center 
through  degeneration  of  the  nucleus;  cell  much  swollen;  c,  cell  similarly  affected  with  edema,  and  showing  a  hardened 
ectoplasm  with  an  edematous  nucleus;  d,  multinuclear  edematous  cell;  e,  multinuclear  edematous  cells-  one  of  the 
nuclei  has  become  surrounded  with  protoplasm,  forming  a  round  cell. 

karyokinesis  were  observed,  and  the  cells  of  the  basal  layer  and  those  immediately 
above  it  showed  numerous  mitotic  figures. 

"  The  inter  epithelial  edema  was  not  pronounced  in  the  middle  and  upper  portion 
of  the  epidermis,  though  here  and  there  it  was  sufficient  in  degree  to  allow  of  leuko- 
cytes making  their  way  between  the  cells  toward  the  basal  layer.  Wide,  irregular 
spaces  were  present,  in  which  were  deformed  prickle-cells,  leukocytes,  and  debris. 
A  number  of  prickle-cells  were  found  to  have  lost  their  fibrillary  skeleton,  the  spon- 
gioplasm  and  its  continuations  into  interepithelial  fibrils  had  disappeared,  and  the 
protoplasm  had  become  homogeneous.  In  this  way  the  cells  had  assumed  a  glob- 
ular appearance.  Many  of  these  cells  lying  immediately  beneath  the  stratum 
corneum  had  become  surrounded  by  a  hardened,  probably  keratinized,  covering. 

"Several  types  of  these  degenerated  cells  were  formed  in  this  way,  and  these 
were  variously  grouped,  e.  g.: 

"  (a)  Round,  swollen  cells  with  a  finely  granular,  almost  homogeneous  proto- 


272  THE    UMBILICUS    AND    ITS    DISEASES. 

plasm,  and  a  darkly  stained  nucleus  lying  in  a  space  or  surrounded  by  a  halo  of 
fluid  protoplasm,  which  stained  faintly. 

* '  These  nuclei  had  chromatin  bodies  and  a  good  intranuclear  network. 

"  (b)  Round  or  oval  cells  with  a  faintly  stained  nucleus,  but  a  more  defined  and 
darkly  colored  ectoplasm,  which  stained  similarly  to  that  of  the  cells  of  the  stratum 
corneum.     These  cells  had  a  slight  resemblance  to  coccidia. 

"  (c)  Cells  in  which,  in  spite  of  the  edema,  an  active  nuclear  division  had  taken 
place,  but  in  which  the  division  of  the  protoplasm  of  the  cell  had  not  kept  pace 
with  that  of  the  nuclei,  and  so  multinucleated  cells  containing  several  oval,  faintly 
stained  nuclei  had  been  produced. 

"  (d)  Groups  of  cells  in  which  the  nuclei  had  become  flattened  and  crescentic  in 
form,  and  a  great  variety  of  shapes  had  resulted.  It  is  unnecessary  to  describe  in 
detail  these  different  groups  and  figures.  Occasionally  a  leukocyte  had  become 
impacted  in  such  a  group  and  further  complicated  it. 

"The  single  cells,  or  'pseudococcidia, '  could  be  demonstrated  by  any  of  the 
ordinary  stains,  such  as  methylene-blue,  hematoxylin,  and  picric  acid  (Banti), 
but  the  most  satisfactory  specimens  of  them  were  obtained  by  staining  the  proto- 
plasm of  the  cell  with  water-blue  and  the  nuclei  with  safranin. 

"The  columnar  epithelial  cells  lining  the  surface  of  the  central  portion  and  the 
follicles  which  dipped  down  from  it  were  seen  under  the  high  power  to  be  very 
regular  in  shape,  and  to  have  oval  nuclei  situated  near  the  base  of  the  cell.  These 
cells  appeared  to  be  perfectly  healthy,  and  showed  no  evidence  of  edema  or  other 
degenerative  process. 

"2.  Changes  in  the  Corium. — The  most  noticeable  feature  in  the  corium  when 
examined  under  the  low  power  was  a  dense  sheet  of  cellular  infiltration,  which 
occupied  the  papillary  and  subpapillary  layers  and  the  upper  portion  of  the  reticular 
layer.  This  infiltration  was  densest  in  the  middle  third  of  the  section,  especially 
where  the  raised  border  existed,  and  in  this  situation  it  was  peculiarly  diffuse  and 
ended  abruptly  below  in  an  almost  straight  line.  It  was  not  quite  so  dense  in  the 
papillae,  and  about  the  blood-capillaries  the  cells  tended  to  be  collected  in  foci.  At 
the  outer  end  of  the  section  it  was  less  diffuse,  and  was  arranged  in  foci  around  the 
papillary  and  subpapillary  blood-vessels,  while  in  the  center,  beneath  the  columnar 
epithelium,  it  was  also  less  dense  and  more  irregular,  and  spread  farther  down  into 
the  underlying  stroma. 

"  With  the  high  power  the  infiltration  was  found  to  consist  largely  of  plasma-cells, 
with  a  few  leukocytes  and  connective-tissue  nuclei.  These  plasma-cells  were 
perfect  in  shape  and  showed  no  tendency  to  special  grouping  or  to  form  giant-cells. 
This  cellular  infiltration  was  thus  more  than  a  simple  inflammatory  infiltrate, 
such  as  is  met  with  in  eczema,  psoriasis,  or  any  acute  inflammatory  condition  of  the 
skin.  It  was  more  closely  allied  to  that  which  occurs  in  certain  of  the  'infective 
granulomata, '  such  as  syphilis  and  yaws,  and  suggested  a  chronic  inflammatory 
process.  Unna  described  it  as  a  singularly  pure  'plasmoma, '  and  Karg  has  likened 
it  to  a  bulwark  against  the  cancerous  invasion. 

"  The  papillae  were  edematous  and  swollen,  especially  in  the  middle  of  the  section. 
The  fibrous  elements  of  the  corium  were  affected  only  in  the  area  of  infiltration. 
There  the  collagen  stained  faintly,  especially  in  the  edematous  papillae,  but  showed 
no  basophilic  degeneration.  The  elastin  was  also  affected  in  that  it  stained  badly, 
was  swollen,  and  formed  an  imperfect  supporting  skeleton. 


paget's  disease  of  the  umbilicus.  273 

''The  blood-vessels  of  the  papillary  and  subpapillary  layers  were  much  dilated, 
and  there  were  a  few  dilated  capillaries  in  the  corium  beneath  the  infiltration." 

(A  brief  resume  of  the  literature  of  Paget's  disease  follows.) 

''Remarks  on  the  Histology  of  our  Case  and  Conclu- 
sions. —  There  are  several  points  of  interest  in  connection  with  the  microscopic 
changes  present  in  our  case  which,  although  they  can  hardly  be  said  to  settle  this 
controversy,  still  are  worthy  of  consideration: 

"1.  Although  the  affected  epidermis  was  that  of  the  umbilicus  and  not  the 
areola  of  the  nipple,  still,  the  changes  present  in  it,  the  peculiar  degenerated  prickle- 
cells,  the  occurrence  of  the  dense  sheet  of  plasma-cells  infiltrating  the  underlying 
papillary  layer  of  the  corium,  in  short,  the  whole  histologic  architecture,  was  similar 
in  every  detail  to  that  which  has  been  repeatedly  described  in  the  typical  cases  of 
the  disease.  These  initial  peculiar  cellular  changes  in  the  epidermis,  allied  some- 
what to  those  which  occur  in  Psorospermosis  follicularis  vegetans  (Darier's  disease), 
could  no  longer  be  mistaken  for  those  of  chronic  eczema  or  psoriasis,  and  it  is 
unnecessary  to  repeat  any  labored  details  with  regard  to  the  histologic  diagnosis 
from  these  affections.  It  would  seem  that  the  histologic  changes  in  the  epidermis 
in  Paget's  disease  are  characteristic  and  pathognomonic,  whether  the  affection 
occurs  in  the  nipple,  the  umbilicus,  or  the  genitalia. 

"2.  In  this  case  there  was  no  evidence  of  definite  malignant  change  in  the  epi- 
dermis. The  degree  of  proliferation  was  limited,  and  the  basal  layer  was  intact. 
It  has  been  asserted  that  the  peculiar  change  of  the  epidermis  is  malignant  from  the 
first.  This  does  not  seem  to  us  to  be  so  any  more  than  that  ordinary  warts,  the 
warty  growth  in  xeroderma  pigmentosum,  or  pigmented  nevi  (moles),  are  malignant 
from  the  outset.  They  may  all  be  described  as  precancerous  lesions  of  the  skin 
which  have  a  potentiality  more  or  less  certain  of  becoming  malignant. 

"3.  The  inclusion  of  a  portion  of  Meckel's  diverticulum  in  the  center  of  the 
umbilicus,  in  this  the  only  case  of  Paget's  disease  which  has  been  recorded  in  that 
situation,  may  be  a  coincidence,  but  it  is  a  suggestive  one.  Cases  have  been 
recorded  in  which  the  cancer  grew  from  the  epithelial  cells  of  mucous  glands,  and, 
had  malignancy  supervened,  it  is  possible  that  it  might  have  taken  its  origin  in  the 
cells  lining  the  follicles  in  the  cut-off  portion  of  gut  in  the  umbilicus.  Still,  in  the 
sections  the  columnar  epithelium  on  the  surface  and  lining  these  follicles  seemed 
perfectly  healthy,  although  the  neighboring  epidermis  was  markedly  affected." 

[The  causative  factor  in  Fox  and  MacLeod's  case  is  clearly  evident.  From  Fig. 
156  it  will  be  seen  that  some  of  the  tubular  glands  which  were  similar  to  those  of  the 
small  intestine  opened  directly  on  the  surface,  and  naturally  produced  some  secre- 
tion which  would  keep  the  parts  moist  and  tend  to  irritate  them.  The  nature  of  the 
man's  occupation  favored  lack  of  systematic  bathing.  During  early  and  middle 
life  nature  was  able  to  resist  any  active  cell  changes,  but  when  he  reached  the  period 
at  which  atypical  cell  changes  are  prone  to  occur,  the  first  symptoms  manifested 
themselves.  From  the  history  it  is  seen  that  he  was  fifty-four  when  this  process 
was  first  noted,  and  that  it  had  gradually  increased  until  he  came  under  observa- 
tion eleven  years  later. 

In  the  case  reported  by  Milligan,  and  later  by  Pinch,  the  patent  urachus  was 
evidently  the  exciting  factor.     It  is  particularly  interesting  that  in  both  of  the 
recorded  cases  the  cause  was  a  congenital  umbilical  defect. — T.  S.  C] 
19 


274  THE    UMBILICUS    AND    ITS    DISEASES. 

Pa  get's  Disease  of  the  Umbilicus  Cured  by  the  Appli- 
cation of  Radium.*  —  "  Mrs.  W.,  aged  thirty-one,  came  complaining  of  a 
smelly  discharge  from  the  navel,  accompanied  by  an  eruption  around  the  navel. 
The  trouble  had  begun  four  years  previously,  with  a  smarting  pain  around  the  waist 
and  a  redness  toward  the  right  side  of  the  umbilicus. 

"Ordinary  remedies  were  tried,  but  with  no  success,  the  condition  steadily  get- 
ting worse.  The  patient  was  then  subjected  to  x-ray  treatment — four  applications 
of  ten  minutes  each.  This  apparently  cured  it,  but  very  shortly  afterward  it  broke 
out  again.  For  twelve  months  or  so  ordinary  remedies  were  resorted  to,  but  with 
no  result.  Again  .r-ray  treatment  was  tried, — six  applications, — but  this  time  it 
got  worse  instead  of  better. 


Fig.  158. — Paget's  Disease  op  the  Umbilicus.     (After  Milligan.) 
The  small  opening  in  the  umbilicus  is  clearly  seen.     Surrounding  this  is  a  granular,  sharply  circumscribed,  raised  area,  in- 
volving the  abdominal  wall  on  all  sides.     The  appearance  of  the  umbilicus  after  the  use  of  radium  is  seen  in  Fig.  159. 

"Sir  Malcolm  Morris  saw  the  patient  in  consultation  about  the  middle  of  June 
last,  and  he  advised  either  total  excision  or  radium  treatment.  Accordingly,  small 
doses  of  radium  were  applied  around  the  edge  of  the  eruption,  which  now  had  a 
radius  of  about  two  inches  from  the  umbilicus.  The  radium  was  applied  in  suc- 
cessive places  around  the  edge,  and  each  place  had  an  exposure  of  four  hours.  This 
certainly  had  a  good  effect,  although  it  did  not  cure  it.  Finally,  on  August  21,  1911, 
at  the  Radium  Institute,  the  patient  had  a  treatment  of  70  mg.  of  pure  radium  for 
one  and  one-half  hours  direct  on  the  skin,  there  being  no  intervening  screen.  For 
ten  days  nothing  was  felt  by  the  patient,  and  then  she  had  a  burning  sensation 
around  the  waist,  and  the  discharge  got  worse.  This  lasted  for  two  weeks,  and 
then  the  skin  healed,  leaving  only  a  small  sore  spot  on  the  right  side. 

"The  condition  prior  to  the  last  application  of  radium  is  well  shown  in  the 

*  Milligan,  W.  A.:  Proc.  Roy.  Soc.  Med.  (Dermat.  Section),  November,  1911,  v,  No.  2,  30. 


PAGET  S    DISEASE    OF    THE    UMBILICUS. 


275 


photograph  [Fig.  158],  and  consisted  of  a  raised,  indurated  edge  all  around,  with  a 
raw  weeping  surface  extending  into  the  umbilicus. 

"The  condition  is  now  apparently  cured  [Fig.  159],  although  there  is  still  some 
discharge,  and  the  question  arises  as  to  whether  there  may  or  may  not  be  a  patent 
urachus.  This  has  not  been  conclusively  proved,  although  at  times  the  discharge 
has  an  ammoniacal  smell.  It  is  interesting  to  note  the  large  close  of  radium  used 
by  Mr.  Pinch  at  the  Radium  Institute,  a  dose  corresponding  to  2,000,000  activities." 

Mr.  A.  E.  Ffayward  Pinch,  when  referring  to  the  same  case,  said  that  a  slight 


Fig.  159. — The  Appearance  in  a  Case  of  Paget's  Disease  of  the  Umbilicus  after  Treatment  with  Radium. 

(After  Milligan.) 
The  umbilicus  is  relatively  smooth,  but  somewhat  paler  than  the  surrounding  tissue.     The  line  of  demarcation  of 
the  tumor  is  still  clearly  evident.     The  skin  around  the  umbilicus  looks  normal,  but  to  the  (patient's)  left  there  ap- 
parently is  still  a  little  thickening.     For  the  appearance  of  the  umbilicus  before  treatment  see  Fig.  15S. 


recurrence  took  place  early  in  September,  1912.  The  same  treatment  was  adopted, 
with  an  equally  good  result,  and  the  patient  since  then  had  remained  perfectly  well. 

Sir  Malcolm  Morris,  chairman  of  the  meeting,  said  that  a  case  of  Paget's  dis- 
ease of  the  umbilicus  was  shown  years  ago  before  the  old  society  by  Mr.  Marmaduke 
Sheild. 

In  1912  I  wrote  Dr.  Milligan  asking  if  it  would  be  possible  for  him  to  send  me 
photographs  of  his  case,  as  the  reproductions  in  the  Proceedings  of  the  Royal  Society 
were  not  very  satisfactory.  Dr.  Milligan  complied  with  my  request  and  sent  me 
the  photographs  here  reproduced. 


276  THE    UMBILICUS    AND    ITS    DISEASES. 

ECZEMA  OF  THE  UMBILICUS. 

This  condition  is  by  no  means  rare,  although  the  literature  on  the  subject  is  very 
meager.  In  the  new-born,  during  the  process  of  cicatrization  of  the  cord,  there 
may  be  slight  irritation  of  the  umbilicus  without  any  evidence  of  infection.  In  an 
adult  with  a  very  delicate  skin  there  may  be  a  slight  irritation  of  the  umbilicus  and 
some  cracking  of  the  skin,  notwithstanding  the  utmost  cleanliness  and  care.  This 
is  prone  to  occur  in  stout  individuals  when  the  weather  is  excessively  warm  and  the 
patient  perspires  a  great  deal.  The  most  common  cause  of  an  eczematous  condi- 
tion around  the  umbilicus  is  the  existence  of  an  umbilical  concretion,  which,  on 
account  of  the  contracted  condition  of  the  umbilical  opening,  is  frequently  over- 
looked. Cantrell.*  in  1897,  and  Morris, f  in  1895,  briefly  discussed  eczema  of  the 
umbilicus.     Umbilical  concretions  are  discussed  in  detail  on  p.  247. 

Recently  I  saw  a  mild  case  of  eczema  of  the  umbilicus  in  consultation  with  Dr. 
Frank  Sladen  in  the  Johns  Hopkins  Hospital.  The  patient  was  eighteen  years  old. 
From  time  to  time  there  had  been  an  irritating  discharge  from  the  umbilicus.  On 
examination  I  found  an  eczematous  condition  in  this  situation.  There  was  a  little 
depression  at  the  side  of  the  umbilical  depression.  There  was  no  evidence  of  a 
concretion. 

*  Cantrell,  J.  A.:  Eczema  Umbilici  and  its  Treatment.     Therap.  Gaz.,  1897,  xxi,  82. 
"  Morris.  R. :  Lectures  on  Appendicitis  and  Notes  on  other  Subjects,  1895,  93. 


CHAPTER  XVIII. 

DIPHTHERIA   OF   THE   UMBILICUS;    SYPHILIS    OF   THE   UMBILICUS; 

TUBERCULOSIS  OF  THE  UMBILICUS;    ATROPHIC   TUBERCULID 

COMMENCING  AT  THE  UMBILICUS. 

Diphtheria  of  the  umbilicus. 

General  consideration. 

Report  of  cases. 
Syphilis  of  the  umbilicus,  at  or  shortly  after  birth. 

Report  of  cases. 
Syphilis  of  the  umbilicus  in  the  adult. 

Report  of  cases. 
Tuberculosis  of  the  umbilicus. 
Atrophic  tuberculid  starting  at  the  umbilicus. 

In  this  chapter  are  grouped  several  diseases  which  are  very  uncommon  and  which 
do  not  belong  to  the  subjects  considered  in  any  other  chapter. 


DIPHTHERIA  OF  THE  UMBILICUS. 

We  have  records  of  only  two  cases  in  which  the  umbilicus  was  the  seat  of  a 
primary  diphtheritic  deposit.  The  first  case  was  described  by  Pitts  in  1897,  the 
second  by  Gertler  in  1898.  As  one  might  naturally  expect,  the  umbilicus  became  in- 
volved shortly  after  birth  and  before  the  umbilical  stump  had  had  time  to  cicatrize. 

Pitts's  patient  was  first  seen  on  the  fourteenth  day  after  birth.  The  child's 
brother  had  just  died  of  diphtheria,  and  its  mother  was  ill  with  the  same  disease. 
Diphtheria  bacilli  were  cultivated  from  the  umbilical  lesion.  The  child  died,  and 
at  autopsy  the  diphtheritic  deposit  was  found  to  be  limited  to  the  umbilicus,  the 
respiratory  tract  being  free  from  membrane. 

Gertler's  patient  first  came  under  observation  when  he  was  four  weeks  old. 
On  the  eighth  day  the  cord,  which  had  not  come  away,  was  cut  off  with  a  pair  of 
scissors  and  the  child  was  circumcised.  When  Gertler  saw  the  patient,  the  umbil- 
icus and  the  penis  presented  the  characteristic  diphtheritic  deposits.  Both  lesions 
yielded  the  specific  bacillus  and  promptly  healed  after  the  use  of  antitoxin. 

Diphtheria  of  the  Umbilicus.*  —  A  child,  fourteen  days  old, 
was  admitted  for  an  inflammation  of  the  umbilicus.  The  cord  had  separated 
on  the  eighth  day,  and  the  resulting  wound  had  continued  to  discharge  extremely 
offensive  pus.  When  seen  on  February  20th,  there  was  a  brawny,  red,  indurated 
area  around  the  umbilicus,  about  the  size  of  a  five-shilling  piece.  From  this  area 
the  epidermis  had  peeled  off.  The  umbilicus  itself  was  the  seat  of  a  dirty-looking, 
wash-leather  slough,  and  was  discharging  offensive  pus  from  an  opening  into  which 
a  probe  could  be  passed  for  about  an  inch.  The  child's  general  condition  was  other- 
wise good.  It  had,  however,  an  occasional  inspiratory  crow,  and  with  it  some  slight 
cyanosis.     The  next  day  it  was  learned  that  the  brother  of  the  child  had  been 

*  Pitts,  B.:  The  Lancet,  London,  1897,  i,  953. 

277 


278  THE    UMBILICUS    AND    ITS    DISEASES. 

removed  to  a  hospital  suffering  with  diphtheria  during  the  previous  week,  and  had 
died  on  the  morning  the  child  was  first  examined.  The  mother  had  been  taken  to  a 
hospital  also  suffering  from  diphtheria. 

A  culture  from  the  umbilicus  examined  on  February  22d  showed  diphtheria 
bacilli.  The  child  had  some  vomiting,  became  weaker,  and  died  on  the  same  day. 
After  death  nothing  abnormal  could  be  found  in  the  larynx  or  pharynx,  nor  had 
the  condition  at  the  umbilicus  extended  to  any  of  the  deeper  structures. 

Diphtheria  of  the  Umbilicus.*  —  The  umbilical  cord  had  not 
come  away  normally,  but  had  been  cut  off  on  the  eighth  day  with  a  pair  of  scissors 
and  the  child  had  been  circumcised.  The  physician  could  not  tell  whether  the 
trouble  had  started  first  in  the  umbilicus  or  on  the  penis.  The  illness  had  lasted 
three  weeks. 

The  child,  four  weeks  old,  was  moderately  well  developed.  In  the  umbilical 
region  was  an  infiltration  of  the  skin  and  underlying  tissue,  and  surrounding  it  was 
a  sharp  line  of  demarcation  which  extended  downward  to  the  symphysis.  Immedi- 
ately around  the  umbilicus  was  a  small,  grayish-yellow  deposit,  and  when  pressure 
was  made  over  the  skin  below  the  umbilicus,  purulent  fluid  escaped. 

The  penis  was  swollen,  and  on  the  right  side  of  the  glans  was  a  flat  ulcer,  like- 
wise covered  with  a  grayish-yellow,  diphtheroid  deposit.  The  inguinal  glands  on 
both  sides  were  hard,  and  the  subaxillary  glands  on  the  right  side  were  enlarged. 
The  pulse  was  96;  the  temperature,  37.8°  C.  Cover-slips  at  once  suggested 
diphtheria,  and  twenty-four-hour  cultures  gave  a  pure  Loffler  bacillus.  The  diag- 
nosis of  diphtheria  of  both  the  penis  and  the  umbilicus  was  certain.  On  October 
27th  the  serum  was  given,  and  on  the  following  day  the  temperature  was  38.2°  C. 
and  the  local  condition  was  better.  The  area  of  redness,  which  had  extended  to  the 
symphysis,  had  narrowed  down  to  2.5  cm.  around  the  umbilicus,  and  the  infiltration 
of  the  skin  was  less. 

On  October  29th  the  skin  infiltration  in  the  umbilical  region  had  disappeared. 
The  skin  was  drawn  up  into  folds,  and  a  grayish-yellow  membrane  came  away  after 
the  use  of  a  3  per  cent,  boric  acid  solution,  leaving  a  superficial  ulcer  which  did 
not  bleed. 

By  October  30th  the  swelling  in  the  umbilical  region  had  become  slightly  smaller, 
and  there  was  no  membrane  over  the  area  of  ulceration.  The  ulcer  of  the  penis 
had  dried  up  entirely. 

On  October  31st  the  umbilicus  presented  the  normal  appearance,  and  the  ulcer 
of  the  penis  had  healed  completely. 


SYPHILIS  OF  THE  UMBILICUS. 

The  literature  on  this  subject  is  very  meager,  but  lues  of  the  umbilicus  has  been 
mentioned  by  Blum  (1876),  Villar  (1886),  Runge  (1893),  Bertherand  and  Merklen 
(1900),  Hutinel  (1903),  Bondi  (1903),  Hartz  (1905),  and  Chiarabba  (1906). 

Cases  of  syphilis  of  the  navel  are  divided  into  two  groups : 

1.  Syphilis  of  the  umbilicus  at  or  shortly  after  birth. 

2.  Syphilis  of  the  umbilicus  in  the  adult. 

*  Gertler,  N. :  Beitrag  zu  den  Krankheiten  des  Nabels  der  Neugeborenen.  Klin,  therapeut. 
Wochenschr.,  Wien,  1898,  v,  1234. 


SYPHILIS   OF   THE   UMBILICUS.  279 


Syphilis  of  the  Umbilicus  At  or  Shortly  After  Birth. 

Bertherand  and  Merklen  in  1900  drew  attention  to  the  fact  that  in  a  certain 
number  of  children  presenting  symptoms  more  or  less  characteristic  of  congenital 
syphilis,  such  as  a  purulent  coryza,  a  tendency  for  the  finger-nails  to  drop  off, 
fissure  in  ano,  etc.,  ulcerations  of  the  umbilicus  existed.  They  were  inclined  to  think 
that  the  umbilical  ulceration  was  part  of  the  syphilitic  process.  In  order  that  the 
reader  may  gain  a  clear  idea  of  their  findings  and  draw  his  own  conclusions,  they 
will  be  cited  here  somewhat  fully. 

Bertherand  and  Merklen  observed,  in  the  service  of  Hutinel,  a  variety  of  umbil- 
ical ulcers  and  thought  these  had  not  been  previously  mentioned.  They  state  that 
Professor  Hutinel  a  long  time  before  had  said  that  these  infections  suggested  syphilis. 
The  ulceration  was  situated  at  the  umbilicus,  and  appeared  shortly  after  birth. 
All  the  patients  examined  by  Bertherand  and  Merklen  were  less  than  one  month 
old.  The  exact  date  of  the  appearance  of  the  ulcer  could  not  be  determined,  as 
all  the  patients  were  brought  to  the  hospital  with  the  lesion  already  present.  The 
youngest  child  was  nine  days  old.  An  ulceration  of  this  character  may  reach  the 
size  of  a  five-franc  piece.  The  base  of  the  ulcer  is  grayish,  sometimes  yellow,  and 
there  is  a  secretion  of  mucopus.  The  ulcer  is  red,  irregular,  has  raised  margins, 
and  one  of  the  cases  showed  appearances  of  gangrene.  The  ulceration  may  be 
accompanied  by  redness  of  the  skin  with  desquamation,  but  without  any  evidence 
of  inflammatory  reaction.  The  authors  further  say  that,  of  the  four  children 
observed,  three  died  of  hereditary  syphilis,  and  that  the  ulceration  still  persisted 
at  the  time  of  their  death.     The  fourth  child  survived  and  the  ulceration  cicatrized. 

Case  1  . — ■  L.  A.,  nine  days  old.  The  child  had  a  purulent  coryza  which 
suggested  syphilis.  There  was  an  ulceration  at  the  umbilicus  which  had  completely 
obliterated  the  umbilical  depression  and  extended  beyond  it.  The  base  of  the 
ulcer  was  grayish,  and  covered  with  a  little  pus.  Around  the  umbilicus  was  a  little 
reddening,  but  only  a  slight  reaction.  The  child  was  cachectic,  lost  weight,  and  died 
ten  days  after  entering  the  hospital.  At  autopsy  nothing  of  moment  was  detected 
in  the  lungs  or  in  the  digestive  tract.  The  brain  was  normal,  but  the  liver  was 
large  and  congested,  and  the  spleen  was  increased  in  size.  The  testicles  were  hard 
and  sclerotic,  but  on  section  did  not  show  anything  of  any  moment.  A  longitudinal 
section  of  the  femur  showed  that  the  bone-marrow  was  altered,  especially  in  the 
upper  and  lower  part.  The  spongy  tissue  of  the  bone  was  yellowish,  and  showed 
less  color  than  normal. 

[In  this  case  it  is  possible  that  syphilis  existed,  but  the  history  is  in  no  way  con- 
clusive. One  might  very  readily  think  of  an  ulcer  at  the  umbilicus  due  to  simple 
infection,  possibly  associated  with  syphilis. — T.  S.  C] 

Case  2.  —  D.  E.  This  child  was  admitted  to  the  hospital  when  eleven  clays 
old.  He  had  a  purulent  coryza,  a  marked  fissure  at  the  anus,  and  erythema  of  the 
buttocks.  No  change  was  noted  in  the  testicles,  and  there  was  no  inflammation  of 
the  nails.  At  the  umbilicus  was  an  ulcer  suggesting  gangrene.  It  was  deep,  had 
irregular  margins,  and  discharged  a  little  mucopus.  A  few  daj^s  later  it  had 
increased  in  size,  become  deeper,  and  was  larger  than  a  five-franc  piece.  The  child 
was  cachectic,  developed  bronchopneumonia,  and  soon  died. 

At  autopsy  evidences  of  bronchopneumonia  were  found  in  both  lungs.  The 
liver  was  red  and  slightly  enlarged,  but  showed  little  on  section.     A  longitudinal 


280  THE    UMBILICUS    AND    ITS    DISEASES. 

section  of  the  left  humerus  gave  a  marked  discoloration  of  the  bone-marrow  at  both 
extremities. 

[In  this  case  the  coryza  and  the  fissure  at  the  anal  margins  point  to  syphilis, 
but  the  area  of  ulceration  at  the  umbilicus  and  the  erythema  of  the  buttocks  might 
equally  well  have  been  due  to  gangrene  or  simple  ulceration  of  the  umbilicus.  The 
case  is  not  clear. — T.  S.  C.J 

Case  3  .  —  N.  S.,  thirteen  days  old,  was  suffering  from  a  purulent  coryza. 
The  diagnosis  of  hereditary  syphilis  was  thought  probable  from  the  existence  of 
an  umbilical  ulcer  which  was  as  large  as  a  five-franc  piece.  The  surface  of  this 
ulcer  was  covered  with  a  greenish,  clear  pus.  The  margins  were  a  little  elevated 
and  desquamated,  and  they  were  also  red,  but  showed  no  induration.  There  was 
but  little  loss  of  tissue.  The  child  developed  an  intestinal  infection.  The  general 
condition  became  alarming,  and  the  umbilical  ulcer  increased  in  size.  Nearly  a 
month  after  the  child's  admission  to  the  hospital  an  inflammation  of  the  extremities 
of  the  nails  of  the  fingers  was  noted,  and  there  was  a  tendency  for  the  nails  to  become 
detached.  The  coryza  continued  without  any  new  manifestations  of  syphilis  except 
the  inflammation  of  the  nails.     The  child  died  a  week  later  of  bronchopneumonia. 

At  autopsy,  in  addition  to  the  bronchopneumonia,  on  histologic  examination,  a 
periportal  sclerosis  and  an  obliterative  endarteritis  were  found.  At  certain  points 
the  obliteration  was  complete.  The  small  hepatic  veins  were  thickened.  The 
hepatic  cells  were  a  little  opaque.  The  left  kidney  was  pale.  The  right  kidney 
was  pale,  and  there  was  a  tendency  to  fusion  of  the  cells.  At  the  upper  extremity 
of  the  kidney  was  a  white,  pearly  gumma,  much  paler  than  the  rest  of  the  renal 
tissue.  The  convoluted  tubules  and  the  loops  of  Henle  were  the  seat  of  a  degenera- 
tion, and  the  glomeruli  were  congested.  The  arteries  of  the  glomeruli  showed  a 
slight  degree  of  endarteritis,  and  some  of  the  arterioles  contained  thrombi.  A  sec- 
tion of  the  superior  extremity  of  the  humerus  demonstrated  that  the  spongy  tissue 
of  the  bone  was  yellowish  and  less  colored  than  normal. 

[In  this  case  the  purulent  coryza  was  suggestive  of  syphilis,  but  the  ulceration 
might  very  readily  have  been  due  to  an  ordinary  infection.  Inflammation  of  the 
extremities  of  the  fingers  also  points  toward  syphilis.  The  report  says  that 
there  was  a  gumma  in  the  right  kidney,  but  the  description  of  the  gumma  is  not  at 
all  conclusive.  This  is  another  case  in  which  we  cannot  say  absolutely  that  the 
umbilical  condition  was  syphilitic. — T.  S.  C] 

Case  4  .  —  C.  C,  one  month  old.  At  the  umbilicus  was  an  ulceration  the 
base  of  which  was  grayish  in  color  and  covered  with  mucopus.  The  ulceration 
was  surrounded  by  a  reddish,  desquamated  zone,  which  was  about  the  size  of  a  two- 
franc  piece.  Two  weeks  later  the  child  commenced  to  improve  and  the  ulcer 
tended  to  diminish.  Shortly  afterward  the  child  showed  the  characteristic  purulent 
coryza,  which  tended  to  confirm  the  idea  of  hereditary  syphilis.  The  ulcer  gradually 
healed  under  simple  local  treatment.  The  coryza,  however,  persisted  with  the 
same  intensity,  and  the  child  was  sent  to  the  country. 

Bertherand  and  Merklen,  in  describing  these  cases,  say  that  the  histories  showed 
that  they  were  dealing  with  hereditary  syphilis,  causing  a  variety  of  ulcers  of  the 
umbilicus.  The  appearance  of  the  lesion,  the  absence  of  general  reaction,  and  the 
coexistence  of  further  signs  of  syphilis,  as  coryza,  fissure  in  ano,  and  inflammation 
of  the  nails,  and  examination  of  the  testicles  would  permit  one,  according  to  their 
view,  to  decide  in  favor  of  the  specific  nature  of  the  umbilical  ulcer. 


SYPHILIS    OF    THE    UMBILICUS.  281 

Hutinel,  in  1903,  wrote  a  very  interesting  article  on  the  same  subject.  He  said 
that  during  the  thirteen  years  in  which  he  had  been  a  physician  to  the  Hopital  des 
Enfants-Assistes  he  had  observed  this  peculiar  umbilical  lesion  about  a  dozen  times. 
From  its  appearance  and  mode  of  development  and  its  anatomic  characteristics 
he  attributed  the  umbilical  trouble  to  hereditary  syphilis.  His  description  of  the 
local  condition  is  very  similar  to  that  given  by  Bertherand  and  Merklen.  Appended 
to  his  paper  are  several  interesting  cases. 

Case  1  .  —  Rena  M.,  born  January  28,  1902,  and  admitted  to  the  hospital  on 
February  18th.  This  child  had  a  purulent  coryza,  a  lorgnette  nose,  and  erythema 
of  the  buttocks.  The  diagnosis  of  hereditary  syphilis  seemed  certain.  Redness  and 
swelling  were  present,  and  a  phlegmonous  appearance,  forming  a  circle  around  the 
umbilicus  and  extending  4  cm.  in  all  directions.  This  area  of  tumefaction  was  not 
hot  nor  painful  on  pressure,  and  had  not  the  definite  margin  characteristic  of  ery- 
sipelas; there  was  no  fever.  In  the  center  of  the  area  was  a  small  ulcer  from  which 
there  was  a  slight  discharge.  At  the  end  of  two  days  the  reddish  circle  had  retracted 
somewhat,  but  the  ulceration  had  increased  in  size  and  deepened.  The  surrounding 
tissue  was  hard,  red,  and  raised,  but  there  was  no  fever.  The  coryza  persisted,  and 
the  characteristic  papules  were  noted  on  the  buttocks.  On  the  following  days  the 
redness  around  the  umbilicus  gradually  took  on  a  livid  tint,  and  in  the  center  was  a 
crater-like  depression,  yellowish  black  and  bloody,  and  several  red  plaques  appeared 
on  the  abdomen.  On  March  3d  the  umbilical  ulcer  formed  a  pit  with  precipitous 
margins,  and  at  the  bottom  the  surface  was  covered  with  a  grayish  exudate.  The 
margins  were  indurated  and  violet-colored.  The  area  of  ulceration  was  about  1.5 
cm.  in  diameter,  and  the  pit  measured  1  to  1.2  cm.  in  depth.  Hutinel  says  that  on 
March  7th  the  ulcerated  area  presented  the  picture  of  a  gumma.  This  had  increased 
in  size  and  its  base  was  yellowish  in  color.  Its  margins  were  precipitous,  but  the 
peripheral  infiltration  had  diminished  and  had  gradually  lost  its  phlegmonous 
aspect.  On  March  10th  the  area  of  ulceration  still  retained  its  principal  char- 
acteristics; the  base,  however,  was  enlarged,  and  the  cutaneous  orifice  had  dimin- 
ished in  size. 

On  March  14th  the  temperature,  which  had  been  absolutely  normal,  reached 
38.2°  C,  the  respirations  became  accelerated,  and  the  child  was  very  restless.  A 
bronchopneumonia  was  evident.  Death  occurred  on  the  following  day.  At  autopsy 
the  peritoneum  at  the  umbilicus  was  found  to  be  normal.  In  the  angle  formed  by 
the  urachus  and  the  umbilical  arteries  there  was  a  yellowish  nodule.  In  a  transverse 
section  of  the  abdominal  wall  this  was  found  to  be  1.4  to  1.5  cm.  in  thickness  at  the 
site  of  the  umbilical  ulcer.  The  abdominal  muscles  on  the  right,  in  the  vicinity  of 
the  ulcer,  were  pale  and  scarcely  recognizable,  and  the  subperitoneal  connective 
tissue  was  thickened  and  presented  a  hyaline  appearance.  The  peritoneum  did 
not  contain  any  liquid,  and  there  were  no  omental  or  intestinal  adhesions.  Broncho- 
pneumonia was  the  cause  of  death. 

From  a  transverse  section  through  the  center  of  the  umbilical  cicatrix  it  was 
found  that  the  floor  of  the  ulcer  consisted  of  a  granular  substance  which  resisted 
the  action  of  the  staining  fluid.  In  the  interval  between  elastic  fibers  could  be 
recognized  remains  of  leukocytes,  and  beneath  this  zone,  where  the  necrosis  had 
been  less  complete,  there  was  an  infiltration  of  round  cells,  and  sometimes  a  few 
leukocytes  which  stained  poorly.  In  the  middle  of  the  area  the  arterioles  appeared 
thickened,  and  in  some  places  had  been  completely  obliterated;   there  existed  an 


282  THE    UMBILICUS    AND    ITS    DISEASES. 

endarteritis  and  sometimes  a  peri-arteritis.  In  some  places  the  infiltration  had 
invaded  the  adipose  tissue. 

[The  general  picture  in  this  case  strongly  suggests  a  mild  umbilical  infection. 
The  histologic  picture  also  is  suggestive  of  the  same  thing.  While  one  cannot  say 
positively  that  syphilis  did  not  exist,  the  evidence  in  favor  of  it  is  not  particularly 
strong.- — T.  S.  C] 

Case  5  .  —  On  p.  90  Hutinel  reports  the  case  of  a  small  girl,  S.  P.,  eight  weeks 
old.  She  was  born  on  March  9,  1903,  and  admitted  to  the  hospital  on  May  5,  1903. 
An  examination  of  this  child  was  made  by  Budin.  The  labor  had  been  normal;  but 
the  father  of  the  child  had  manifested  symptoms  of  syphilis  and  appeared  to  have 
tuberculosis.  The  child  at  birth  weighed  3600  grams.  On  March  11th,  after  the 
expulsion  of  meconium,  the  child's  weight  dropped  to  3400  gm.,  but  by  March  15th 
it  had  risen  to  3650  gm.  On  March  20th,  when  the  mother  left  the  clinic,  the  child 
had  not  gained  a  gram  in  weight,  and  it  was  noted  that  the  umbilicus  was  diseased. 
It  was  red  and  raised,  and  a  superficial  ulcer  was  noted  above  and  to  the  right. 
The  child  had  coryza.  Sublimate  baths  were  prescribed,  and  the  umbilical  ulcer 
was  painted  with  iodin,  and  afterwards  with  silver  nitrate;  in  addition,  the  child 
was  given  mercurial  frictions.  She  remained  in  the  clinic  until  April  30th, 
when  the  area  of  ulceration  appeared  to  be  healing.  It  did  not  heal,  however, 
and  on  May  5th,  when  the  child  was  brought  for  examination,  the  ulcer  was  found 
to  be  large  and  deep.  The  mother  said  that  from  the  beginning  the  umbilicus  was 
swollen  and  red  over  an  area  the  size  of  a  five-franc  piece,  and  that  it  had  become 
eaten  out  and  had  suppurated,  after  which  the  redness  had  disappeared.  The 
swelling  had  been  replaced  by  a  depression,  and  there  had  remained  at  the  umbilicus 
a  triangular  ulcer.  The  margins  of  the  ulcer  were  sharply  denned,  the  skin  was  red 
around  the  orifice,  and  a  pinkish,  serous  fluid  escaped.  The  child  was  very  pale 
and  had  a  yellowish,  waxy  tint  that  led  one  to  suspect  syphilis.  The  head  was  large, 
the  nose  lorgnette-shaped.  There  were  no  fissures  of  the  lips  and  no  inflammation 
of  the  nails.  There  was  an  erysipelas  of  the  legs  and  arms  and  some  papules  on  the 
buttocks.  The  epiphyses  were  a  little  enlarged,  but  there  was  no  bone  malforma- 
tion. There  was  some  thickening  of  the  cranial  bones.  The  liver  was  slightly 
enlarged,  and  the  spleen  was  somewhat  increased  in  size.  On  May  9th  the  umbilical 
ulcer,  which  had  resisted  treatment  for  six  weeks,  contracted  and  tended  to  dis- 
appear. Hutinel  says  that  the  fact  that  syphilis  existed  in  this  case  is  undeniable^ 
and  that  the  mother,  on  May  22d,  presented  in  the  throat  a  very  characteristic 
papulo-erosive  syphilitic  eruption. 

Some  of  the  cases  reported  by  Bertherand  and  Merklen  and  by  Hutinel  were  in 
all  probability  instances  of  congenital  syphilis,  but  whether  the  umbilical  lesions 
were  directly  caused  by  the  spirochete  or  not  is  another  question.  Runge,  in  speak- 
ing of  wound  infections  of  the  new-born,  said  that  when  the  syphilitic  manifesta- 
tions make  their  appearance  at  birth,  usually  in  premature  children,  these  children 
are  born  dead,  die  almost  immediately,  or  live  only  a  few  hours,  rarely  a  day.  He 
further  says  that,  in  addition  to  the  usual  syphilitic  changes  in  these  cases,  there  are 
numerous  hemorrhages  under  the  skin  and  in  the  internal  organs. 

Bondi  says  the  diagnosis  of  hereditary  syphilis  in  the  new-born  is  very  diffi- 
cult. He  covers  the  literature  well,  gives  a  large  number  of  cases,  and  also  presents 
some  excellent  pictures.  His  conclusion  is  excellent:  "There  were  present  the 
exudate  with  an  inflammatory  appearance,  the  edematous  infiltration  of  the  vessel- 


SYPHILIS    OF    THE    UMBILICUS.  283 

walls,  with  migration  of  polymorphonuclear  leukocytes,  and  in  one  case  a  pouring- 
out  of  fibrin  and  in  two  cases  abscess-like  formations  in  the  vessel-walls,  and  some- 
times necroses.  In  one  case  there  was  a  deposit  of  chalk."  He  says  that  the  changes 
are  due  to  an  arteritis  and  phlebitis;  that  the  picture  presented  is  not  specific  or 
characteristic,  but  the  changes  described  have  been  those  observed  only  in  syphilis, 
and  that,  in  the  absence  of  proof  to  the  contrary,  we  can  with  a  moderate  degree  of 
certainty  describe  these  as  the  pathologic  findings  in  syphilis. 

The  umbilical  pictures  presented  by  the  cases  here  recorded  are  so  similar  to 
those  due  to  the  umbilical  infection  formerly  so  frequent  shortly  after  birth  that, 
anatomically,  they  show  little  or  no  difference ;  and  even  the  histologic  pictures  of 
these  supposedly  syphilitic  lesions  of  the  umbilicus  are  by  no  means  conclusive. 
If  syphilis  existed  in  these  cases,  the  lowered  vitality  of  the  child  would  naturally 
render  it  more  susceptible  to  any  umbilical  infection.  While  our  knowledge  of  this 
subject  is  meager,  careful  examinations  of  umbilical  ulcers  for  the  Spirochseta  pallida 
will,  in  the  future,  speedily  determine  whether  these  ulcerations  are  syphilitic  or  not. 

Syphilis  of  the  Umbilicus  in  the  Adult. 

Blum,  in  his  article  on  Tumors  of  the  Umbilicus  in  the  Adult,  published  in  1876, 
when  speaking  of  syphilis,  mentions  the  case  of  a  man,  aged  thirty-six,  who  had  a 
fetid  discharge  from  the  umbilicus  for  two  years.  The  umbilicus  was  prominent 
and  formed  a  tumor.  Its  margins  were  swollen  and  possibly  slightly  ulcerated. 
Dupuytren  considered  the  probability  of  a  fecal  fistula,  but  Breschet,  who  had  seen 
several  analogous  cases,  prescribed  a  specific  treatment,  and  the  patient  was  cured. 
From  the  clinical  picture  this  case  might  equally  well  have  been  one  of  umbilical 
concretion,  particularly  if  any  local  treatment  was  given. 

Bille,  in  1912,  collected  eight  cases  of  primary  syphilis  of  the  umbilicus,  and  in 
1914  referred  to  three  others.  In  the  latter  article  he  shows  the  picture  of  a  lesion  in 
a  young  girl  coming  under  the  care  of  Lassar.  At  the  umbilicus  was  an  elongated, 
oval  ulcer  the  size  of  a  five-pfennig  piece.  The  ulcer  was  deep,  and  its  surface 
brownish  red  and  glistening.  Its  margins  were  sharply  defined  and  infiltrated. 
Surrounding  the  ulcer  was  a  pale  red,  inflammatory  zone. 

The  following  case,  observed  by  Fiaschi,  was  so  carefully  studied  that  I  shall 
report  it  in  detail : 

Syphilitic  Chancre  of  the  Umbilicus.  —  In  1911  I  received 
the  following  from  Dr.  P.  Fiaschi,  of  Sydney,  Australia: 

"178  Phillip  St.,  Sydney,  Australia,  March  14,  1911. 
.  .  .  "As  you  are  busy  with  your  paper  on  the  umbilicus,  I  thought  you  might 
like  the  following:  Some  three  weeks  ago  I  found  a  young  man  with  a  chancre  of 
the  inner  aspect  of  the  right  lower  quadrant  of  the  prepuce  and  a  chancre  of  the 
umbilicus  (Fig.  160).  He  gave  a  history  of  an  incubation  of  fourteen  and  seventeen 
clays.     .     .     . 

"I  may  say  that  my  father  concurred  in  the  diagnosis  of  genital  and  extragenital 
primitive  infection  of  the  young  man.  The  ultramicroscopic  examination  gave 
me  one  of  the  finest  specimens  of  spirochetes  I  have  managed  to  get  from  any  lesion 
in  any  case  I  have  examined  so  far.  Inasmuch  as  you  are  interested  in  this  work, 
you  might  look  up  the  classic  monograph  of  our  distinguished  master,  M.  Le  Pro- 
fesseur  Founder.  You  will  find  the  report  on  page  284  and  subsequent  pages. 
Fournier,  in  a  personal  observation  of  110  extragenital  chancroids,  in  a  total  of 
10,000  chancres  that  he  has  observed  in  private  practice,  found  only  16  of  the 
abdomen.     They  are  evidently  not  common. 


284  THE    UMBILICUS    AND    ITS    DISEASES. 

"The  result  of  the  injection  of  salvarsan  was  very  striking.  Both  lesions  had 
cicatrized  in  five  days,  so  that  even  after  vigorously  using  an  ophthalmic  curet  I 
could  not  get  any  spirochetes." 

On  May  25,  1911,  Dr.  Fiaschi  writes: 

"The  young  man  took  it  into  his  head,  after  seeing  his  lesions  healed,  to  leave  this 
city  and  go  to  a  country  town,  telling  me  that  he  knew  he  was  cured,  judging  by  the 
reports  that  he  had  read  in  magazines  and  newspapers.  He  did  this  notwithstand- 
ing my  remonstration  not  to  fool  himself,  but  to  place  himself  under  the  usual 
methodic  mercurial  treatment.  I  wanted  to  present  him  to  a  clinical  meeting  of 
our  local  medical  society,  and  I  wrote  him  to  come  to  Sydney,  and  he  did  so  the 
day  before  the  meeting.     On  presenting  himself  I  found  that  both  lesions  had 


Fig.  160. — Syphilis  of  the  Umbilicus.     (Fiaschi.) 
The  umbilical  depression  is  filled  with  dome-like  elevations  of  various  sizes,  and  trickling  from  the  umbilical  orifice 
is  a  watery  discharge.     Spirochetes  were  obtained  from  the  umbilicus  and  also  from  a  chancre  of  the  prepuce.    Both 
lesions  yielded  promptly  to  salvarsan.     The  patient  did  not  keep  up  the  necessary  treatment,  and  returned  two  months 
later  with  a  mucous  patch  on  the  upper  lip. 

remained  healed,  but  that  he  had  a  mucous  patch  on  the  upper  lip,  the  size  of  a 
nickel,  from  which  I  obtained  numerous  spirochetes  under  the  ultramicroscope,  of 
the  giant  form,  such  as  are  frequently  found  in  mucous  patches.  I  had  this  mucous 
patch  photographed,  and  am  pleased  to  write  you  that  I  am  now  mailing  you,  under 
registered  cover,  four  photographs,  two  of  the  chancre  and  one  showing  the  result 
five  days  after  intramuscular  injection  of  salvarsan,  and  the  fourth  showing  the 
relapse  with  mucous  patch.  The  young  man  told  me  that  he  had  noticed  this  two 
weeks  before  seeing  me." 

LITERATURE  CONSULTED  ON  SYPHILIS  OF  THE  UMBILICUS. 
Bertherand  et  Merklen:    Sur  une  varietc  d'ulceration  ombilicale  de  nature  syphilitique.     Bull. 

de  la  Soc.  de  ped.  de  Paris,  1900,  ii,  248. 
Blum,  A.:    Tumeurs  de  l'ombilic  chez  l'adultc.     Arch.  gen.  de  med.,  Paris,  1876,  vi.  ser..  xxviii, 

151. 


TUBERCULOSIS    OF    THE    UMBILICUS.  285 

Bondi,  Josef:    Die  syphilitischen  Veranderungen  der  Nabelschnur.     Arch.  f.  Gyn.,  1903,  lxix, 

223. 
Chiarabba,  U. :  Contributo  alia  Conoscenza  della  sifilide  ombelicale  (Flebite  proliferativa  gommosa 

della  vena  ombelicale).     Annali  di  ostetricia  e  ginecologia,  1906,  Anno  28,  i,  190. 
Fiaschi,  P. :   Personal  communication. 
Fournier,  A.:  Les  chancres  extra-genitaux,  Paris,  1897,  326. 

Hartz,  A.:  Abnabelung  und  Nabelerkrankung.     Monatsschr.  f.  Geb.  u.  Gyn.,  1905,  xxii,  77. 
Hutinel,  V.:    L'ulcere  syphilitique  de  l'ombilic  chez  les  nouveau-nes.     La  Syphilis,  Paris,  1903, 

i,  81. 
Pernice,  Ludwig:   Die  Nabelgeschwiilste,  Halle,  1892. 
Rille:   Ueber  den  syphilitischen  Primaraffekt  am  Nabel.     Festschr.  f.  E.  Lesser,  Arch.  f.  Derm., 

1912,  cxiii,  865. — Ein  weiterer  Beitrag  zur  Kenntnis  des  syphilitschen  Primaraffektes  am 

Nabel.     Dermatol.  Wochenschr.,  1914,  lix,  1271. 
Runge:   Die  Wundinfectionskrankheiten  der  Neugeborenen.   Die  Krankheiten  der  ersten  Lebens- 

tage,  2.  Aufl.,  1893,  194. 

tuberculosis  of  the  umbilicus. 

Bouffleur,*  in  1898,  reported  a  supposed  case  of  tuberculosis  of  the  umbilicus. 
The  patient  had  been  complaining  only  for  ten  days.  He  first  had  cramp-like 
pains  in  the  abdomen,  followed  three  days  later  by  a  discharge  from  the  umbilicus 
with  tenderness  and  soreness  in  the  umbilical  region.  The  discomfort  was  so 
marked  that  he  had  to  stop  work. 

Several  sisters  had  died  of  tuberculosis,  but  the  patient,  apart  from  repeated 
chancroidal  infections  and  an  occasional  attack  of  colicky  pain  followed  by  diar- 
rhea, after  drinking  beer,  had  been  perfectly  well. 

On  examination  a  purulent  discharge  was  noted  at  the  umbilicus,  and  to  the 
right  and  below  the  umbilicus  was  a  slight  swelling,  apparently  situated  in  the  deeper 
part  of  the  abdominal  wall.  The  purulent  tract  was  enlarged,  and  with  a  curet 
over  an  ounce  of  typical  tuberculous  granular  tissue  was  removed.  A  cavity  the 
size  of  a  walnut,  internal  to  the  abdominal  wall,  was  exposed.  It  was  packed  with 
iodoform  gauze.  Some  of  the  smears  yielded  large  numbers  of  tubercle  bacilli; 
others  contained  none. 

Bouffleur  asks  whether  this  was  a  case  of  tuberculosis  of  a  blind  urachus  or  of 
Meckel's  diverticulum. 

[The  clinical  picture  is  strongly  suggestive  of  a  soft  umbilical  concretion. — 
T.  S.  C] 

In  1911,  in  the  course  of  a  conversation  with  Dr.  A.  L.  Stavely,  of  Washington, 
he  referred  to  an  interesting  case  which  had  come  under  his  observation.  On  March 
26,  1904,  he  sent  the  specimen  to  Dr.  J.  R.  Mohler,  of  the  Bureau  of  Animal  Indus- 
try, who,  in  reply  to  an  inquiry  from  me,  reported  as  follows : 

"Slides  were  prepared  which  showed  numerous  tubercle  bacilli  with  the 
Ziehl-Nielsen  stain.  Two  guinea-pigs  were  inoculated  with  the  material,  and  both 
developed  tuberculosis. 

"No  sections  of  the  umbilicus  were  made,  but  we  still  have  slides  prepared  from 
the  pus  in  the  fistulous  tract,  which  show  the  presence  of  tubercle  bacilli,  somewhat 
faded  as  a  result  of  nine  years'  preservation. " 

Tuberculosis  of  the  umbilicus  is,  to  say  the  least,  exceedingly  rare.  One  might 
expect  occasionally  to  find  it  in  those  rare  cases  in  which  a  tuberculous  bowe 
becomes  adherent  to  and  opens  through  the  umbilicus. 

*  Bouffleur,  Albert  I.:  Tuberculosis  of  the  Umbilicus.     Clin.  Rev.,  Chicago,  1898,  ix,  329. 


286 


THE    UMBILICUS    AND    ITS    DISEASES. 


A  CASE  OF  ATROPHIC  TUBERCULIDE 

The  patient  was  a  boy,  aged  twelve,  who  had  been  under  Bunch's  care  for  five 
years  at  the  Queen's  Hospital  for  Children,  and  before  that  under  Dr.  Adamson's 
care  at  the  same  hospital.  The  latter  had  shown  him  before  the  Dermatological 
Society  of  London  on  May  9,  1906.  The  eruption  had  begun,  when  the  child  was 
aged  four,  as  a  single  red  patch  at  the  navel,  on  which  small  red  nodules  had  developed 
later.  The  nodules  were  slightly  raised,  somewhat  papular  in  character,  and  dis- 
tinctly infiltrated.  They  had  a  tendency  to  necrose,  and  always  left  a  superficial, 
shallow  scar  about  x/%  inch  to  l/i  inch  in  diameter. 

In  1906  there  were  about  30  such  scars  around  the  umbilicus,  and  scattered 


Fig.  161. — Atrophic  Tuberculid  Starting  at  the  Umbilicus.     (After  J.  L.  Bunch.) 

Scattered  over  the  lower  abdomen  and  right  thigh  and  over  the  region  of  the  right  shoulder  are  elevations,  oval  or 

round  in  form.     They  were  first  noted  at  the  umbilicus. 


among  these  were  about  a  dozen  raised  red  papules,  ranging  in  size  from  a  millet- 
seed  to  a  split-pea.  During  the  succeeding  years  similar  necrotic  papules  had  made 
their  appearance  in  the  inguinal  region,  on  the  thighs,  on  the  upper  part  of  the  but- 
tocks, in  front  of  and  behind  both  axillae,  and  on  the  shoulders  and  back  (Fig.  161). 
Attention  was  called  to  the  fact  that  the  nodules  and  scars  were  always  pre- 
ceded by  a  circumscribed,  irregular,  dry,  scaly,  red  dermatitis,  such  as  had  been 
described  in  1906  for  the  inner  side  of  the  thigh  and  arm,  where  there  were  now  the 
characteristic  scars.  Similar  appearances  had  preceded  the  atrophic  tuberculid 
elsewhere,  and  there  was  now  a  very  well-marked  patch  of  such  a  dermatitis  on 
the  right  shoulder,  which  probably  denoted  the  appearance  of  the  nodular  eruption 
within  the  next  year  or  two. 

*  Bunch,  J.  L.:  Proc.  Roy.  Soc.  Med.  (Dermatological  Section),  November,  1911,  v,  21. 


CHAPTER  XIX. 

THE  ESCAPE  OF  RETROPERITONEAL  AND  ABDOMINAL  FLUID  FROM 
THE  UMBILICUS;  THE  OPENING  OF  AN  APPENDIX  ABSCESS  AT 
THE  UMBILICUS;  ABSCESS  OF  THE  LIVER  OPENING  AT  THE 
UMBILICUS;  PERITONITIS  WITH  THE  ESCAPE  OF  PUS  FROM 
THE  UMBILICUS;  THE  PIECEMEAL  REMOVAL  OF  A  SUPPURAT- 
ING OVARIAN  CYST  THROUGH  THE  UMBILICUS. 

The  escape  of  retroperitoneal  fluid  from  the  umbilicus. 

A  periprostatic  abscess  opening  at  the  umbilicus. 

A  thoracic  abscess  opening  at  the  umbilicus;  report  of  cases. 

A  broad-ligament  abscess  opening  at  the  umbilicus. 

Cases  of  broad-ligament  abscess  opening  at  or  near  the  umbilicus. 
An  abscess  of  the  umbilical  vein  in  an  adult. 
The  opening  of  an  appendix  abscess  at  the  umbilicus. 
Abscess  of  the  liver  opening  at  the  umbilicus. 
Peritonitis  with  the  escape  of  pus  at  the  umbilicus,  clinical  picture;   causes  of  the  peritonitis; 

differential  diagnosis;   report  of  cases. 
The  piecemeal  removal  of  a  suppurating  ovarian  cyst  through  the  umbilicus. 
Localized  jaundice  of  the  umbilicus  with  the  presence  of  free  bile  in  the  abdominal  cavity. 

THE  ESCAPE  OF  RETROPERITONEAL  FLUID  FROM  THE  UMBILICUS. 

An  effusion  of  fluid  into  the  retroperitoneal  tissue  will  tend  to  loosen  up  the  peri- 
toneum from  the  underlying  adipose  or  muscular  tissue  by  a  process  of  dissection, 
the  process  gradually  extending  for  quite  a  distance.  For  example,  in  February, 
1912,  I  saw  with  Drs.  Smouse,  Fay,  and  Priestley,  in  Des  Moines,  Iowa,  a  patient 
giving  the  history  of  the  sudden  development  of  a  more  or  less  globular  tumor  to 
the  left  of  and  above  the  umbilicus.  The  man  passed  into  a  state  of  collapse  and 
was  thought  to  be  dying.  A  few  days  later  his  condition  was  much  improved,  and 
an  exploratory  abdominal  operation  was  deemed  advisable.  On  opening  the 
abdomen  I  could  palpate  a  mass,  about  10  cm.  in  diameter,  in  the  region  of  the 
pancreas.  The  peritoneum  of  the  right  abdominal  wall  was  bluish  in  color,  and 
the  mesocecum  much  thickened.  I  at  once  closed  the  abdomen  and  made  a  gridiron 
incision  in  the  right  iliac  fossa,  pushing  the  peritoneum  toward  the  median  line. 
The  discoloration  of  the  peritoneum  was  due  to  the  action  of  old  blood  which  had 
dissected  this  membrane  from  the  underlying  structures.  As  I  passed  my  fingers 
upward  toward  the  right  renal  pocket  I  found  that  between  the  peritoneum  and  the 
lateral  abdominal  wall  there  was  a  space,  fully  2  cm.  broad,  which  was  filled  with 
clotted  blood.  Surrounding  the  right  kidney  there  was  also  a  very  large  blood-clot. 
A  drain  was  laid  in  the  pelvis  and  in  the  right  renal  pocket,  care  being  taken  not  to 
dislodge  the  clots.     The  man  did  well  for  over  a  week  and  then  died  suddenly. 

At  autopsy  an  aneurysm  of  the  abdominal  aorta  was  found  (Fig.  162).  This 
had  perforated  posteriorly  and  on  the  left  side,  producing  the  tumor  that  had  sud- 
denly appeared  on  the  left  of  the  median  line.  This  blood  had  gradually  passed 
over  the  vertebral  column  and  gradually  dissected  free  the  peritoneum  on  the  right 

287 


288 


THE    UMBILICUS   AND    ITS    DISEASES. 


side  of  the  abdomen,  a  fact  which  accounted  for  the  disappearance  of  the  tumor  on 
the  left.  The  sudden  death  had  been  due  to  rupture  of  the  aneurysm  into  the  duod- 
enum. Careful  examination  at  autopsy  showed  that  the  peritoneum  on  the  right 
lateral  abdominal  wall,  as  a  result  of  the  hemorrhage,  had  been  dissected  from  the 
underlying  structures  as  far  as  the  right  internal  inguinal  ring. 

If  blood  under  pressure  can  find  its  way  extraperitoneally  from  one  part  of  the 
abdominal  wall  to  another,  there  is  no  reason  why  pus  under  pressure  should  not  do 
the  same  thing.  In  a  psoas  abscess  we  have  a  good  example  of  the  extraperito- 
neal burrowing  of  pus. 


Aortic  aneurysm 

Fig.  162. — Leakage  from  an  Abdominal  Aneurysm  Producing  a  Temporary  Abdominal  Tumor;  Subsequent 
Escape  of  the  Blood  into  the  Right  Renal  Pocket. 
H.  S.  W.,  February  16,  1912.  In  I,  we  see  an  aneurysmal  dilatation  of  the  aorta.  In  II,  the  aneurysmal  sac  has 
given  way,  with  the  escape  of  blood  retroperitoneally.  This  caused  the  tumor  that  was  noted  clinically.  The  pressure 
of  the  escaping  blood  gradually  dissected  the  peritoneum  free,  and  the  blood,  following  the  line  of  the  arrows,  gradually 
passed  over  into  the  right  renal  pocket,  as  noted  in  III.  At  operation  I  found  the  peritoneum  over  the  lateral  wall  of 
the  lower  abdomen  bluish  black.  This  was  due  to  the  presence  of  old  blood  lying  between  the  peritoneum  and  the 
muscles  of  the  lateral  abdominal  walls.  At  autopsy  it  was  found  that  the  blood  had  dissected  its  way  extraperitoneally 
as  far  as  the  right  internal  inguinal  ring. 

A  Periprostatic  Abscess  Opening  at  the  Umbilicus. 
Nicaise  refers  to  the  case  of  a  patient  under  the  care  of  Castaneda.     A  peri- 
prostatic abscess  gradually  extended  and  opened  at  the  umbilicus.     In  Fig.  163 
is  indicated  the  manner  in  which  a  periprostatic  abscess  may  reach  the  navel. 


Thoracic  Abscess  Opening  at  the  Umbllicus. 
Both  Blum  and  Nicaise  refer  to  a  case  reported  by  Curran  in  the  Lancet  in  1872. 
A  young  boy  in  the  beginning  had  symptoms  of  a  right-sided  pneumonia.     Resolu- 
tion failed  to  take  place,  and  cachexia  soon  developed.     The  boy  looked  as  if  he 
had  tuberculosis.     At  the  end  of  six  months  an  elevation,  which  was  exceedingly 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS. 


289 


painful,  developed  just  above  the  xiphoid  and  extended  to  the  umbilicus.  It  soon 
opened,  and  an  enormous  quantity  of  pus  escaped,  the  purulent  discharge  from  the 
umbilicus  continuing  for  fourteen  days.  The  pulmonary  symptoms  disappeared, 
and  the  boy  was  able  to  go  back  to  his  occupation  permanently  cured.  The  abscess 
in  this  case  had  evidently  been  walled  off  by  the  cellular  tissue  between  the  attach- 
ment of  the  diaphragm  and  the  sternum.     Whether  an  abscess  of  the  lung  had 


Fig.  163. — The  Manner  in  which  a  Periprostatic 
Abscess  may  Occasionally  Escape  at  the  Um- 
bilicus. 

The  periprostatic  abscess  may  gradually  dissect  free 
the  peritoneum  of  the  lateral  and  anterior  abdominal 
wall  and  reach  the  umbilicus.  This  has  occurred  in  a 
few  instances,  but  it  is  unusual,  the  abscess,  as  a  rule, 
tending  to  empty  itself  into  the  bowel,  bladder,  or  ex- 
ternally. 


Fig.  164. — Escape  of  Pleural  Fluid  from  the  Um- 
bilicus. 
This  is  a  schematic  representation  of  the  manner  in 
which  a  purulent  accumulation  in  the  pleural  cavity  may 
break  through  the  diaphragm,  gradually  dissect  free  the 
peritoneum  over  a  limited  area,  and  finally  escape  at  the 
umbilicus.  In  some  cases,  after  the  pus  has  broken 
through  the  diaphragm,  a  fistulous  tract  has  been  found 
extending  intraperitoneally  down  over  the  liver  to  the 
umbilicus. 


existed  or  whether  there  had  originally  been  an  accumulation  of  pus  in  the  pleural 
cavity  could  not  be  determined. 

Fig.  164  depicts  in  a  schematic  way  the  manner  in  which  an  empyema,  after 
perforating  the  diaphragm,  may  travel  downward  and  forward  until  it  reaches  the 
umbilicus. 

A  Broad-Ligament  Abscess  Opening  at  the  Umbilicus. 

According  to  Nicaise,  Fereol  was  the  first  to  describe  a  case  of  this  kind; 
Bernutz  and  Guerin  had  also  reported  cases  of  phlegmon  of  the  broad  ligament 
opening  at  the  umbilicus. 
20 


290 


THE    UMBILICUS    AND    ITS    DISEASES. 


Probably  the  most  interesting  articles  on  the  subject  are  those  of  Yaussy,  pub- 
lished in  1875,  and  of  Gauderon,  published  in  1876. 

We  are  all  familiar  -with  the  induration  that  is  occasionally  found  in  one  or  both 


Abscess 

in 
broad  tig. 


Fig.  105. — The  Opening  of  a  Broad  Ligament  Abscess  at  the  Umbilicus.  (Schematic.) 
Broad  ligament  abscesses  are  most  frequently  observed  after  postpuerperal  infections.  Occasionally  they  form 
definite  hard  or  boggy  masses  that  can  be  readily  palpated  in  one  or  both  iliac  fossa?.  In  rare  instances  the  infection 
extends  beyond  the  confines  of  the  broad  ligament.  The  pus  dissects  the  peritoneum  of  the  lateral  and  anterior 
abdominal  wall  free  over  a  limited  area,  and  finally  escapes  through  the  umbilicus,  following  the  course  roughly  outlined 
by  the  arrows. 


broad  ligaments,  and  which,  as  a  rule,  has  resulted  from  an  infection  following  labor. 
Although  such  an  inflammation  is  usually  limited  to  the  uterus,  it  may  gradually 
separate  the  folds  of  the  broad  ligament  and  appear  as  a  more  or  less  indurated 
nodule  in  the  right  or  left  iliac  fossa,  and  occasionally  in  both.     If  the  tendency 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  291 

toward  suppuration  continues,  a  further  lifting  up  of  the  peritoneum  may  occur, 
and  in  this  manner  the  pus  may  travel  up  to  the  umbilicus  (Fig.  165) . 

In  nearly  all  the  reported  cases  the  patients  have  given  a  history  more  or  less 
typical  of  a  mild  puerperal  sepsis.  After  a  period  varying  from  a  few  days  to 
several  months'  induration  was  noted  at  or  near  the  umbilicus.  This  was  in  some 
instances  accompanied  by  marked  induration  of  the  abdomen  between  the  umbilicus 
and  pubes.  The  center  of  the  umbilical  induration  gradually  softened.  In  some 
cases  it  opened  spontaneously;  in  others  it  was  opened  before  rupture  had  time  to 
occur.  The  amount  of  pus  escaping  varied  greatly,  depending  in  large  measure  on 
the  size  of  the  broad-ligament  abscess.  The  umbilical  opening  usually  remained 
patent  until  the  abscess-sac  ceased  to  drain.  In  Vaussy's  Case  1,  however,  it  would 
temporarily  close,  only  to  discharge  again.  In  the  cases  reported  by  Fereol  and 
by  Sottas,  and  in  Vaussy's  Case  6,  the  abscess  also  opened  into  the  vagina. 
None  of  the  patients  died  as  a  direct  result  of  the  abscess. 

Treatment.- — •  Sometimes  it  is  possible  to  make  counter-drainage,  as  in 
Sottas'  case,  in  which  a  rubber  tube  was  carried  from  the  umbilicus  to  the  vagina. 
If  the  abscess  is  large,  it  may  be  possible  to  enter  the  broad  ligament  from  the 
vagina,  but  much  care  must  be  exercised  to  avoid  injuring  the  ureter  or  uterine 
artery.  When  vaginal  drainage  does  not  seem  feasible,  the  ordinary  gridiron 
incision,  as  for  an  appendix  operation,  should  be  made;  the  peritoneum  should  be 
gradually  pushed  toward  the  median  line  until  the  broad  ligament  is  reached  and 
the  abscess  evacuated. 

Cases  of  Broad-Ligament  Abscess  Opening  at  or  Near  the  Umbilicus. 

The  following  cases  were  encountered  in  looking  up  the  literature  on  diseases 
of  the  umbilicus.  There  have  doubtless  been  other  cases  recorded  in  the  general 
obstetric  and  gynecologic  literature.  The  number  here  cited  is,  however,  sufficient 
to  give  a  clear  idea  of  the  direction  which  abscesses  in  the  broad  ligament  may 
occasionally  take. 

Fistula  at  the  Umbilicus  Following  Suppuration  in 
the  Left  Broad  Ligament.  — ■  Nicaise  said  the  first  observation  of  this 
kind  was  mentioned  by  Fereol.*  Inflammation  of  the  left  broad  ligament  followed 
the  labor.  There  then  developed  a  local  peritonitis,  which  later  became  general. 
At  the  same  time  the  left  side  of  the  abdomen  became  tumefied  and  there  was  dulness 
on  percussion.  Toward  the  fifteenth  day  a  small  tumor  appeared  above  and  to  the 
left  of  the  umbilicus.  It  was  hard,  fluctuating,  and  opened  spontaneously.  Floods 
of  pus  escaped,  soaking  several  draw-sheets  during  the  night.  Several  days  after 
another  perforation  took  place,  this  time  into  the  vagina.  The  umbilical  fistula 
cicatrized  in  the  course  of  six  weeks. 

Phlegmon  of  the  Left  Broad  Ligament  and  of  the 
Right  Broad  Ligament;  Subperitoneal  Escape  of  Pus 
by  the  Rectum;  Escape  of  Pus  Below  the  Umbilicus; 
H  e  a  1  i  n  g  .  f  —  Marie  Noel,  twenty-two  years  of  age,  was  the  mother  of  two 
children,  one  born  in  March,  the  other  in  December,  1875.     After  the  labor  she 

*  Fereol  (Quoted  by  Nicaise):  Ombilic.  Dictionnaire  encyclopedique  des  sci.  med.,  Paris, 
1881,  2.  ser.,  xv,  140. 

f  Gauderon,  E.:  De  la  peritonite  idiopathique  aigue  des  enfants;  de  sa  terminaison  par  sup- 
puration et  par  evacuation  du  pus  a  travers  rombilic.     These  de  Paris,  1876,  148. 


292  THE    UMBILICUS    AND    ITS    DISEASES. 

came  under  the  care  of  Siredey.  On  December  20th  a  phlegmon  of  the  left  broad 
ligament  was  noted,  and  on  February  5th  there  was  a  similar  condition  in  the 
right  broad  ligament.  About  February  20th  a  thickening  was  made  out  in  the 
anterior  abdominal  region,  commencing  three  fingerbreadths  beneath  the  anterior 
superior  spine  on  the  right,  and  reaching  almost  to  the  umbilicus.  Pus  had  been 
discharged  by  rectum  on  February  12th.  The  abdominal  tumor  persisted  and 
progressed  toward  the  median  line,  apparently  following  the  direction  of  the  urachus 
toward  the  umbilicus.  Pressure  caused  severe  pain  below  the  umbilicus.  On 
February  11th  fluctuation  had  been  noticed  below  the  umbilicus,  and  an  opening 
had  been  made  at  this  point  which  allowed  the  escape  of  a  large  quantity  of  creamy, 
thick  pus.  The  umbilicus  was  never  distended  in  the  manner  indicating  the 
presence  of  a  hernia. 

Suppuration  of  the  Tube  and  Ovary,  with  Opening 
at  the  Umbilicus.  *  —  A  woman,  twenty-four  years  of  age,  was  admitted 
to  Viannay's  clinic  in  August,  1910,  on  account  of  an  abscess  which  had  opened  at 
the  umbilicus.  She  had  had  a  child  twenty-three  months  before,  but  no  mis- 
carriages. Forceps  were  used  at  the  labor.  No  fever  followed.  When  she  com- 
menced to  get  up,  pain  was  noted  in  the  right  iliac  fossa.  Some  time  later  the 
abdomen  was  opened  by  Dr.  Blanc  for  a  salpingo-oophoritis.  Recovery  followed, 
but  when  the  menses  returned,  pain  was  noted  in  the  iliac  fossa.  There  was  a 
periodic  purulent  discharge  from  the  uterus  and  pain  in  the  lower  abdomen.  Little 
by  little  she  developed  a  purulent  accumulation  around  the  umbilicus.  This 
opened  spontaneously  and  discharged  an  abundance  of  purulent  material. 

When  admitted  to  the  hospital,  a  small  abscess  the  size  of  a  walnut  was  noted 
in  the  lower  part  of  the  umbilical  cicatrix.  This  had  a  punctiform  orifice.  The 
disproportion  between  the  small  size  of  the  abscess  and  the  great  abundance  of 
the  umbilical  discharge  was  very  striking.  On  vaginal  examination  an  induration 
was  found  in  the  right  lateral  cul-de-sac. 

Operation. — The  umbilical  opening  was  increased  in  size  and  an  abscess  found 
in  the  subcutaneous  tissue.  The  fistulous  tract  passed  down  the  median  line  behind 
the  muscle  and  the  aponeurosis.  The  median  incision  was  continued  to  within  two 
fingerbreadths  of  the  symphysis.  A  finger  was  introduced  into  the  fistulous  tract, 
and  counter-palpation  made  through  the  vagina.  Finally  the  abdominal  finger 
opened  up  an  abscess,  which  was  drained  from  above.  The  vagina  was  not  opened. 
The  patient  made  a  good  recovery. 

[This  would  appear  to  have  been  a  broad-ligament  abscess. — T.  S.  C] 

Umbilical  Fistula  Following  Puerperal  Sepsis. — - 
Nicaisef  cites  the  case  of  one  of  Pujol's  patients.  The  peritonitis  developed  in  a 
woman  shortly  after  confinement.  A  little  later  there  was  pain  at  the  umbilicus 
and  a  small  tumor  formed,  with  a  soft  swelling  around  it.  It  was  opened  with  a 
lancet  and  pus  escaped.  A  sound  introduced  into  the  tract  did  not  pass  to  the  peri- 
toneum. On  the  fourth  day,  in  the  depth,  another  tumor  could  be  felt  passing 
from  the  primary  abscess.  It  opened  spontaneously  through  the  same  opening, 
and  a  large  quantity  of  pus  escaped.     The  fistula  closed  in  about  six  months. 

*  Maurin:    Salpingo-ovarite  suppuree,  ouverte  a  l'ombilic.     La  Loire  medicale,  1910,  annee 
29,  495. 

t  Nicaise  (Pujol):  Op.  cit. 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  293 

Subperitoneal  Phlegmon  of  the  Anterior  Abdominal 
Wall  Spontaneously  Opening  at  the  Umbilicus;  Puru- 
lent Pleurisy,  Followed  by  Recovery.*  —  Case  1. — This  pa- 
tient was  twenty-one  years  of  age  and  was  admitted  in  May,  1875.  Fourteen  days 
previously  she  had  had  a  normal  labor,  and  four  days  later  a  chill,  and  the  lochia 
had  ceased.  The  abdomen  increased  in  size,  but  there  was  no  vomiting  or  nausea. 
On  March  17th  the  umbilicus  became  red,  projected  somewhat,  and  showed  a 
whitish  point  in  its  center.  During  the  night  of  the  eighteenth  this  ulcerated  and 
there  was  a  discharge  of  greenish  liquid  containing  grumous  material.  During  the 
evening  the  opening  increased  in  size.  By  March  21st  the  discharge  at  the  umbili- 
cus had  diminished.  On  April  3d  it  was  very  slight,  but  on  the  ninth  the  umbilicus 
opened  again  spontaneously  and  two  liters  of  grumous,  greenish  pus  escaped.  The 
patient  continued  to  have  an  appetite.  There  was  some  fever  at  night.  By 
November  12th  the  patient  had  improved  very  much  and  was  convalescing.  During 
the  first  few  months  recovery  was  retarded  by  a  purulent  pleurisy.  It  was  sup- 
posed that  this  patient  had  had  a  purulent  peritonitis,  and  for  that  reason  she  was 
admitted  to  the  hospital.  Vaussy,  however,  was  not  certain  that  the  condition 
was  not  due  to  inflammation  of  the  perimetrium,  with  extension  to  the  umbilicus. 

[The  latter  explanation  would  seem  to  be  the  more  rational  one. — T.  S.  C] 

Inflammation  of  the  Left  Broad  Ligament  Follow- 
ing Labor;  Local  Peritonitis,  Mammary  Abscess,  In- 
flammation of  the  Femoral  Vein,  Spontaneous  Per- 
foration of  the  Abdominal  Wall  in  the  Neighborhood 
of  the  Umbilicus,  also  Opening  into  the  Vagina.  Cica- 
trization of  the  Umbilical  and  Vaginal  Fistulae.  Death 
Due  to  Tuberculosis  of  the  Lungs. f  —  P.  R.,  aged  twenty-four, 
a  healthy  woman,  was  delivered  on  October  26,  1859.  The  labor  was  difficult. 
On  October  31st  the  lochia  ceased;  the  patient  had  a  chill  for  half  an  hour.  The 
abdomen  became  painful  in  the  left  inguinal  region.  The  pulse  was  small,  thready, 
frequent,  and  there  was  much  thirst.  The  next  day  the  lochia  reappeared  in  small 
quantities.  The  abdomen  was  tympanitic,  painful  in  the  lower  left  side,  where 
a  tumefaction  could  be  felt  in  the  broad  ligament.  On  November  2d  the  chills 
were  constant  and  prolonged.  The  abdomen  was  swollen  and  painful.  Pressure 
was  intolerable.  There  was  nausea  without  vomiting,  and  the  face  was  pale  and 
drawn.  The  pulse  was  small  and  frequent,  and  the  skin  hot  and  dry.  On  Novem- 
ber 20th  a  phlebitis  appeared  in  the  left  limb.  On  November  28th  a  small  tumor 
was  felt  in  the  neighborhood  of  the  umbilicus.  It  was  immediately  below  and  a 
little  to  the  left,  and  was  the  size  of  a  pigeon's  egg.  It  was  hard,  although  fluctuant. 
On  November  30th  an  abscess  presented  in  its  center,  a  small  plaque  about 
the  size  of  a  20-centime  piece,  from  which  a  serous,  transparent  fluid  was  dis- 
charged. On  December  1st  a  considerable  quantity  of  greenish,  serous  pus  escaped, 
which  had  a  rather  fetid  odor.  The  abdomen  diminished  in  size,  and  the  tumor 
in  part  disappeared.  On  December  5th  there  was  diarrhea,  and  the  patient  had 
a  left  intermammary  abscess.     She  also  suffered  pain  in  the  left  lower  abdomen. 

*  Vaussy,  F. :  Des  phlegmons  sous-p£ritoneaux  de  la  paroi  abdominale  anterieure.  These 
de  Paris,  1875,  No.  445. 

t  Vaussy,  F.:  Op.  cit.,  Case  6. 


294  THE    UMBILICUS    AND    ITS    DISEASES. 

The  night  preceding  she  had  been  inundated  with  pus  that  had  escaped  from  the 
vagina.  On  the  seventh  the  diarrhea  continued;  the  discharge  from  the  vagina 
diminished,  but  was  abundant  from  the  umbilicus.  The  chills  appeared  every  day 
about  2  or  3  o'clock.  There  were  definite  signs  of  pulmonary  tuberculosis.  In  the 
early  part  of  January  some  improvement  was  noted.  The  fistula  closed  completely, 
the  appetite  returned,  and  the  patient  seemed  to  be  on  the  point  of  recovery. 
Toward  the  end  of  January  both  lungs  were  found  to  be  involved,  and  the  patient 
died  on  February  24,  1860.  At  autopsy  it  was  found  that  the  intestinal  loops 
were  bound  to  one  another  by  an  old  false  membrane.  Both  lungs  were  infiltrated 
with  tubercles. 

In  this  case  a  woman,  several  days  after  labor,  had  a  phlegmon  of  the  broad 
ligament,  which  was  extraperitoneal.  It  invaded  the  iliac  fossa  and  the  anterior 
abdominal  wall,  and  there  formed  in  this  region,  extraperitoneally,  a  large,  purulent 
collection  which  reached  to  the  umbilicus.  The  peritoneum  was  in  contact  with  the 
abscess  and  became  inflamed,  whence  there  resulted  a  circumscribed  adhesive 
peritonitis.  Four  weeks  after  labor  the  tumor  opened  at  the  umbilicus,  and  several 
days  later  a  new  opening  took  place  spontaneously  into  the  vagina.  This  latter 
opening  was  at  the  dependent  portion  of  the  abscess.  The  patient  commenced  to 
improve,  but  pulmonary  tuberculosis  suddenly  developed.  The  autopsy  demon- 
strated an  old  peritonitis,  but  no  trace  of  any  recent  pus. 

Suppurative  Pelvic  Peritonitis  Opening  Spontane- 
ously at  the  Umbilicus.- — ■  Vaussy*  reports  a  case  observed  by  Sottas, 
an  intern  in  the  service  of  Marrotte,  and  published  in  L'Union  medicale,  June  2, 
1864.  R.  A.,  aged  twenty-three,  was  delivered  of  a  child  in  the  eighth  month. 
After  labor  the  patient  had  fever  but  no  pain  and  no  abdominal  distention.  There 
was  nothing  to  indicate  peritonitis.  She  left  the  hospital  on  April  22d,  and  three 
days  later  returned  with  all  the  symptoms  of  pelvic  peritonitis.  At  that  time  an 
abscess  is  said  to  have  opened  into  the  vagina.  In  the  course  of  two  months  she 
was  again  admitted  to  the  hospital.  She  complained  of  pain  in  the  left  iliac  fossa, 
and  said  that  she  had  a  tumor.  In  the  month  of  September  the  swelling  disappeared 
and  the  patient  left  the  hospital  in  good  health.  She  entered  the  hospital  again  on 
December  14,  1863.  In  the  hypogastric  region  was  an  ovoid  tumor,  fairly  firm,  and 
painful  on  pressure.  In  the  iliac  fossa  was  an  irregular  solid  tumor.  The  illness 
was  attributed  to  a  relighting  up  of  the  old  pelvic  inflammation.  On  January  2d 
fluctuation  was  noted  in  the  hypogastric  region,  but  this  was  so  superficial  that  it 
was  thought  to  be  subcutaneous.  The  hypogastric  region  was  prominent,  and 
occupying  it  was  a  round  tumor.  At  the  umbilicus  it  was  possible  to  feel  the  super- 
ior portion  of  the  tumor,  which  was  round  and  fluctuating.  On  examination  the 
cervix  was  found  to  be  back  against  the  sacrum.  Between  the  uterus  and  the 
symphysis  was  a  round,  soft  tumor.  Examination  was  painful,  and  the  skin  of 
the  abdomen  was  red  and  suggested  a  phlegmon.  On  the  night  of  January  5th 
a  small  nodule  which  had  formed  just  below  the  umbilicus  opened;  there  was  a 
free  escape  of  pus,  and  the  hypogastric  region  became  flatter.  Later  Bernutz  and 
Gosselin  saw  the  patient ;  a  probe  introduced  at  the  umbilicus  passed  down  toward 
the  vagina.  On  the  tenth  Gosselin  dilated  the  umbilical  orifice,  punctured  the 
vagina,  and  brought  the  probe  through.  A  rubber  tube  was  then  passed  from  the 
umbilicus  through  into  the  vagina.     On  the  nineteenth  the  urine  escaped  from  the 

*  Vaussy,  F.:  Op.  cit.,  Case  7. 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  295 

umbilicus,  and  colored  matter  injected  into  the  bladder  escaped  from  the  vagina 
and  also  from  the  umbilicus.* 

The  discharge  of  urine  gradually  ceased  from  the  umbilicus,  and  on  February 
1st  the  patient  voided  without  a  catheter.  The  suppuration  from  the  umbilicus 
and  from  the  vagina  had  ceased.  On  February  6th  the  patient  had  chills  and  fever 
and  the  pain  in  the  abdomen  reappeared.  On  February  13th  the  umbilical  fistula 
opened  again,  and  a  seropurulent  discharge  came  away.  On  February  20th  it  was 
noted  that  the  discharge  had  ceased  for  several  days  and  the  patient  was  in  good 
condition.  In  the  left  iliac  fossa  could  be  felt  an  indurated  tumor,  but  the  patient 
remained  well. 

[In  this  case  there  was  probably  a  broad-ligament  abscess.  Peritonitis  cannot 
be  absolutely  excluded.] 

An  Abscess  of  the  Umbilical  Vein  in  an  Adult. 

This  case  hardly  belongs  in  this  chapter,  but  can  be  better  considered  here  than 
elsewhere.  As  a  rule,  the  umbilical  vein  has  long  since  disappeared,  but  from  Dr. 
Barlow's  description  it  seems  quite  probable  that  the  abscess  here  described  devel- 
oped in  a  partially  patent  umbilical  vein. 

An  Abscess  of  the  Umbilical  Vein  in  an  Adult,  f ' — • 
The  patient  was  a  male,  white,  aged  forty.  At  the  age  of  fifteen  he  began  to  have 
sporadic  attacks  of  pain,  cramp-like  in  character,  very  severe,  and  coming  on  nearly 
always  at  night,  after  retiring.  These  attacks,  as  a  rule,  were  of  short  duration. 
Two  or  three  days  after  the  pain  was  over  the  patient  was  apparently  perfectly 
well  again  until  the  next  attack. 

On  the  evening  of  January  14,  1915,  the  patient  was  taken  with  severe  pain 
involving  the  whole  right  abdomen.  The  pain  was  so  severe  that  it  caused  him 
to  draw  his  knees  up  and  to  cry  out.  He  had  no  chills  and  was  not  jaundiced; 
temperature,  101°  F.;  nausea  and  vomiting  once.  Dr.  E.  C.  McGehee,  the  family 
physician,  examined  him  thoroughly  and  made  a  diagnosis  of  acute  infection  of  the 
gall-bladder.  One-quarter  of  a  grain  of  morphin  failed  to  relieve  the  pain,  and  it 
was  necessary  to  allow  him  to  inhale  chloroform  before  any  relief  could  be  obtained. 
Dr.  Barlow  saw  him  in  consultation  next  morning.  At  that  time  the  temperature 
was  100°  F.;  the  entire  abdomen  was  distended;  the  acute  pain  was  subsiding; 
the  area  of  tenderness  was  localizing  between  the  umbilicus  and  the  liver,  and  the 
patient  was  sensitive  under  the  right  costal  arch.  Immediate  operation  was  advised, 
but  the  patient  did  not  consent  until  a  week  later. 

Operation. — The  usual  gall-bladder  incision  was  made,  but  as  he  was  opening 
the  peritoneum  Dr.  Barlow  entered  an  abscess  which  he  thought  was  the  gall- 
bladder. Exploration  with  the  finger  disclosed  the  fact  that  it  was  not  the  gall- 
bladder but  a  well-walled-off  abscess  containing  about  one  and  one-half  ounces  of 
pus.  This  abscess  in  shape  resembled  a  bottle-gourd,  the  larger  portion  being 
toward  the  umbilicus,  the  smaller  or  handle-like  end  extending  into  the  fissure  of 
the  liver.  This  abscess  was  firmly  fixed  to  the  abdominal  wall,  to  the  upper  border 
of  the  liver  above  the  gall-bladder,  and  to  the  hepatic  flexure  of  the  colon. 

After  this  sac  had  been  dissected  free  from  these  attachments  it  was  still  found 

*  We  would  now  administer  phenolphthalein,  which  would  give  the  reddish  discharge  from  the 
vagina  and  also  from  the  umbilicus. 

j  Dr.  E.  E.  Barlow,  Dermott,  Ark.     Personal  communication. 


296  THE    UMBILICUS    AND    ITS    DISEASES. 

anchored  to  the  fissure  of  the  liver  by  the  handle-like  portion  of  the  sac,  which 
proved  to  be  the  umbilical  vein.  This  was  patulous  within  an  inch  of  its  bifurca- 
tion.    It  was  ligated  above  the  patulous  portion  and  removed. 

The  stomach,,  duodenum,  pancreas,  gall-bladder  and  its  ducts  were  examined 
and  found  to  be  normal.  The  portion  of  the  hepatic  flexure  of  the  colon  that  was 
adherent  to  the  sac  was  somewhat  lacerated,  and  in  the  presence  of  infection  Dr. 
Barlow  did  not  feel  justified  in  attempting  to  repair  it.  There  was  no  evidence  of 
ulceration  at  this  point,  the  damage  being  due,  as  Dr.  Barlow  says,  to  an  extensive 
dissection.  A  large  coffer-dam  drain  was  laid  down  between  the  liver  and  intestine. 
This  was  removed  on  the  fifth  day.  Two  days  later  a  fecal  fistula  appeared  but 
closed  after  five  or  six  days.  The  patient  made  an  uneventful  recovery,  and  at  the 
time  of  the  report  was  apparently  well. 

LITERATURE  CONSULTED  ON  THE  ESCAPE  OF  RETROPERITONEAL  FLUID 

FROM  THE  UMBILICUS. 

Fereol:  Nicaise:  Ombilic.  Dictionnaire  encyclopedique  des  sci.  med.,  Paris,  1881,  2.  ser.,  xv, 
140. 

Gauderon,  E.:  De  la  peritonite  idiopathique  aigue  des  enfants;  de  sa  terminaison  par  suppura- 
tion et  par  evacuation  du  pus  a  travers  l'ombilic.     These  de  Paris,  1876,  No.  148. 

Maurin:  Salpingo-ovarite  suppuree,  ouverte  a  l'ombilic.     La  Loire  medicale,  1910,  annee  29,  495. 

Nicaise:   Op.  cit. 

Vaussy,  F. :  Des  phlegmons  sous-peritoneaux  de  la  paroi  abdominale  anterieure.  These  de  Paris, 
1875,  No.  445. 

THE  OPENING  OF  AN  APPENDLX  ABSCESS  AT  THE  UMBILICUS. 

An  appendix  abscess,  in  the  vast  majority  of  cases,  naturally  is  intra-abdominal, 
and  hence  there  is  little  opportunity  of  its  passing  upward  in  the  abdominal  wall 
unless  the  abscess  has  destroyed  the  peritoneum  of  the  anterior  abdominal  wall  over 
the  abscess  area,  or  unless,  as  happens  very  rarely,  the  appendix  from  the  begin- 
ning has  been  retroperitoneal.  In  an  experience  extending  over  twenty  years  I 
have  never  seen  the  umbilicus  involved  in  an  appendix  case.  In  the  literature  I 
have,  however,  found  several  cases  which  seem  to  indicate  an  extension  to  the 
umbilicus. 

Vaussy*  reports  a  very  interesting  case:  A  girl,  sixteen  years  of  age,  was  ad- 
mitted on  October  27,  1875.  Seven  months  previously  she  had  suddenly  vomited, 
had  had  diarrhea,  but  no  abdominal  pain.  Three  months  later  the  pain  had 
become  severe  in  the  hypogastric  region  and  the  patient  had  noticed  a  tumor  occu- 
pying the  right  iliac  fossa.  This  was  painful  on  pressure.  She  had  had  no  chills, 
no  nausea  or  vomiting.  In  the  course  of  two  months  this  tumor  had  increased  in 
size,  and  the  pain  had  become  more  severe,  lancinating  in  character,  and  insuffer- 
able. The  patient  had  lost  her  appetite  and  had  fever,  and  her  general  condition 
was  much  altered.  The  tumor  had  become  fluctuant.  Two  incisions  were  made, 
and  about  500  c.c.  of  pus  escaped.  Several  days  later  a  small  red  plaque  appeared 
below  the  umbilicus,  and  there  was  a  tumor  the  size  of  a  cherry.  This  opened  spon- 
taneously with  the  passage  of  a  certain  amount  of  pus.  There  was  also  a  discharge 
of  pus  from  the  umbilicus.  Toward  the  end  of  September  the  opening  cicatrized. 
When  seen  on  October  27th  the  patient  was  again  pale,  and  there  was  a  purulent 

*  Vaussy:  Op.  cit.,  Obs.  3,  p.  27. 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  297 

discharge  from  the  umbilical  region  and  also  from  the  site  of  the  incision.  By 
November  11th  the  patient  was  in  excellent  condition  and  looked  as  if  she  were 
getting  well.  [While  one  cannot  say  that  this  was  primarily  a  case  of  appendicitis, 
the  picture  strongly  indicates  it. — T.  S.  C] 

Gauderon,  in  his  thesis  in  1876,  refers  to  the  same  case. 

Bryant  and  Hine,  in  1878,  reported  a  case  in  which  the  escape  of  pus  was  in  all 
probability  appendiceal  in  origin,  as  indicated  by  the  perforated  cecum  detected 
at  autopsy.  A  boy,  aged  thirteen,  had  pain  in  the  lower  abdomen  and  also  soreness 
at  the  umbilicus,  together  with  a  fecal  fistula  at  that  point.  He  had  been  delicate 
since  an  attack  of  scarlet  fever  when  three  years  old.  His  legs  were  scalded  when 
he  was  eleven  years  old,  and  since  then  he  had  lost  weight.  His  bowels  had  always 
been  loose.  Three  weeks  before  admission  he  had  sudden  pain  in  the  abdomen, 
and  a  week  later  his  umbilicus  began  to  swell,  became  purple,  and  in  a  few  days 
burst,  discharging  a  quantity  of  matter  with  a  distinctly  fecal  odor.     The  boy  died. 

At  autopsy  the  cecum  was  found  to  have  ulcerated  through,  and  the  ulceration 
had  extended  along  the  abdominal  wall  to  the  umbilicus.  The  symptoms  in  this 
case  strongly  suggested  appendicitis  or  an  inflamed  Meckel  diverticulum. 

Kelly  and  Hurdon  report  an  interesting  case  coming  under  the  care  of  R.  L. 
Payne,  of  Norfolk,  Va.  The  patient,  a  colored  woman  twenty  years  old,  after 
repeated  attacks  of  appendicitis,  developed  a  tumor  at  the  umbilicus.  When  an 
incision  was  made  in  the  mid-line,  just  beneath  the  umbilicus,  half  a  pint  of  fetid 
pus  escaped  and  the  appendix  floated  out.  The  patient  recovered,  but  a  fistula 
persisted. 

We  have  here  considered  only  those  appendix  cases  in  which  an  abscess  was 
present,  and  in  which  no  general  peritonitis  existed.  For  a  description  of  the 
umbilicus  in  cases  of  peritonitis  see  p.  299. 


LITERATURE  CONSULTED  ON  THE  OPENING  OF  AN  APPENDIX  ABSCESS  AT  THE 

UMBILICUS. 

Bryant  and  Hine:   Fecal  Umbilical  Fistula.     Med.  Times  and  Gaz.,  1878,  i,  460. 

Gauderon,  E.:  De  la  peritonite  idiopathique  aigue  des  enfants;  de  sa  terminaison  par  suppura- 
tion et  par  evacuation  du  pus  a  travers  l'ombilic.     These  de  Paris,  1876,  148. 

Kelly  and  Hurdon:  The  Vermiform  Appendix  and  its  Diseases.  Phila.,  W.  B.  Saunders  Co., 
1905,  202. 

Vaussy,  F. :  Des  phlegmons  sous-peritoneaux  de  la  paroi  abdominale  anterieure.  These  de  Paris, 
1875,  No.  445. 


ABSCESS  OF  THE  LIVER  OPENING  AT  THE  UMBILICUS. 

Berard,  in  1840,  wrote  on  abscess  of  the  liver  opening  at  the  umbilicus. 

Leguelinel  de  Lignerolles,  in  1869,  said  that  hepatic  fistulae  opening  at  the  um- 
bilicus might  be  due  to  a  calculous  tumor,  to  hydatids,  or  originate  from  an  abscess 
of  the  liver.  He  then  reported  in  detail  several  cases  in  which  biliary  calculi  and 
echinococci  escaped  at  the  umbilicus,  but  has  little  to  say  regarding  hepatic  ab- 
scesses opening  at  the  umbilicus. 

Nicaise,  when  summing  up  the  subject,  says  that  abscess  of  the  liver  does  not, 
as  a  rule,  tend  to  open  externally,  and  that,  judging  from  the  statistics  of  Rendu, 
the  majority  of  these  abscesses  do  not  open  spontaneously.  When  rupture  takes 
place,  the  pus  tends  to  pass  toward  the  thoracic  more  frequently  than  into  the 


298  THE    UMBILICUS    AND    ITS    DISEASES. 

abdominal  cavity.  In  those  rare  cases  in  which  the  abscess  tends  to  escape  externally 
the  point  of  exit  is  liable  to  be  in  the  region  of  the  right  hypochondrium,  beneath 
the  costal  margin,  where  the  abscess  becomes  walled  off  and  then  ruptures.  Nicaise 
says  that  he  knew  of  but  one  case,  that  of  Ronis,  in  which  a  liver  abscess  opened 
directly  at  the  umbilicus.  Judging  from  a  casual  glance  over  the  literature  one 
would  infer  that  an  escape  of  the  contents  of  a  liver  abscess  from  the  umbilicus 
was  not  rare,  but  when  we  come  to  analyze  the  cases,  it  will  be  found  that  in  nearly 
every  instance  the  umbilical  fistula  was  due  to  an  infected  gall-bladder  which  had 
become  adherent  to  and  opened  at  the  umbilicus,  as  evidenced  by  the  escape  of  gall- 
stones with  the  pus. 

The  opening  of  a  liver  abscess  at  the  umbilicus  is  a  very  rare  occurrence. 


LITERATURE  CONSULTED  ON  ABSCESS  OF  THE  LIVER  OPENING  AT  THE  UMBILICUS. 

Berard,  P.  H.:  Fistules  de  l'ombilic.     Diet,  de  med.,  Paris,  1840,  xxii,  64. 
Nicaise:   Op.  cit. 

Leguelinel  de  Lignerolles,  H.:    Quelques  recherches  sur  la  region  de  l'ombilic  et  les  fistules  hepa- 
tiques  ombilicales.     These  de  Paris,  1869,  No.  6. 


PERITONITIS  WITH  THE  ESCAPE  OF  PUS  AT  THE  UMBILICUS. 

From  time  to  time  isolated  cases  of  peritonitis  with  escape  of  the  pus  from  the 
umbilicus  have  been  recorded.  Among  the  earlier  writers  on  the  subject  were 
Bricheteau  in  1839,  Cazaban  in  1845,  Aldis  in  1848,  and  Baizeau  in  1875.  The  most 
exhaustive  treatise  that  we  possess  is  the  excellent  thesis  of  Gauderon,  published 
in  1876,  and  even  to-day  this  monograph  contains  the  most  illuminating  discussion 
of  the  subject.  Nicaise,  in  1881,  gave  a  very  complete  review  of  the  literature,  and 
Cameron,  in  the  Proceedings  of  the  Royal  Society  of  London,  February,  1912,  adds 
some  very  interesting  data. 

Clinical  Picture. 

As  pointed  out  by  Gauderon,  this  disease  occurs  almost  exclusively  in  girls. 
Boys,  however,  are  occasionally  attacked.  Of  the  cases  described  here  more  or 
less  in  detail,  and  where  the  sex  was  mentioned,  12  occurred  in  girls  and  1  in  a  boy. 

Age.  — ■  The  youngest  child  was  a  year  old,  the  oldest,  seventeen.  In  15  cases 
in  which  we  have  data  as  to  the  age,  14  of  the  patients  were  under  twelve  years  of 
age. 

Symptoms.  —  The  child  is  usually  attacked  suddenly  with  severe  abdom- 
inal pain.  When  seen,  the  legs  are  drawn  up,  the  face  has  an  anxious  expression, 
the  pulse  is  rapid  and  small,  the  temperature  elevated ;  the  tongue  is  often  red,  and 
the  skin  hot.  As  the  disease  progresses  there  may  be  much  vomiting  associated 
with  diarrhea.  In  fact,  in  Baizeau's  case  the  gastro-intestinal  symptoms  were  so 
accentuated  that  cholera  was  suspected.  The  exact  condition  is  often  very  obscure. 
In  Cameron's  Case  6  appendicitis  was  first  suspected,  and  later  the  child  was  sup- 
posed to  be  suffering  from  pneumonia.  In  Cameron's  Case  7  the  symptoms 
strongly  suggested  typhoid  fever. 

As  the  disease  progresses  the  child  may  become  delirious,  as  noted  in  Aldis'  and 
Baizeau's  cases,  and  emaciation  become  marked.  After  a  period  varying  from  a 
few  days  to  several  weeks  fluid  is  detected  in  the  abdomen,  and  a  little  later  the 
umbilicus  becomes  prominent.   Thus,  in  Triboulet's  case,  referred  to  by  Gauderon,  for 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  299 

example,  on  the  eighth  clay  a  small,  elevated  tumor  formed  at  the  umbilicus.  This 
was  diagnosed  as  an  umbilical  hernia,  and  an  attempt  made  to  reduce  it.  In  Cam- 
eron's Case  6,  on  the  other  hand,  it  was  ten  weeks  before  any  umbilical  swelling  was 
noted.  There  is  usually  an  unfolding,  as  it  were,  of  the  umbilicus,  and  a  tumor  is 
formed.  The  umbilical  skin  may  be  normal  or  somewhat  thinned  out.  The  tumor 
contains  free  fluid,  and  when  this  has  been  forced  back  into  the  abdomen,  the 
hernial  ring  can  at  times  be  easily  felt.  This  forcing  back  of  the  fluid  into  the 
abdomen  is  sometimes  accompanied  by  a  considerable  amount  of  gurgling.  As  a 
rule,  there  is  little  or  no  evidence  of  inflammation  at  the  umbilicus.  In  Cazaban's 
case,  however,  there  was  a  phlegmonous  inflammation  at  the  umbilicus,  and  in 
Triboult's  case  the  umbilicus  was  indurated. 

Gauderon  says  that  pus  may  escape  from  the  umbilicus  as  early  as  the  twelfth 
day,  but  that,  as  a  rule,  it  comes  away  between  the  twentieth  and  thirtieth  days. 
In  some  cases  the  umbilical  prominence  became  red  and  opened  in  its  center;  in 
other  cases,  after  the  application  of  poultices,  there  was  a  sudden  discharge  of  pus, 
much  to  the  surprise  of  the  physician  or  attendant.  If  there  has  been  much  abdom- 
inal tension,  the  pus  will  naturally  escape  in  jets  until  the  pressure  has  been  relieved. 
It  varies  greatly  in  appearance.  In  some  cases  it  was  spoken  of  as  a  purulent  fluid; 
in  others,  as  that  of  a  serous  peritonitis,  while  in  several  cases  it  was  thick  and  green 
in  color.  In  some  cases  it  was  odorless;  in  others,  foul-smelling.  The  amount 
of  pus  also  varied  greatly.  In  some  cases  it  was  estimated  that  several  liters 
escaped. 

Sometimes  the  fistula  would  remain  open  for  weeks  and  then  close.  In  other 
cases  it  would  seal  over -and  open  up  again,  only  to  repeat  this  procedure  several 
times. 

In  some  cases  it  was  found  necessary  to  irrigate  the  abdominal  cavity  frequently 
before  the  purulent  secretion  could  be  checked.  The  earliest  permanent  closure 
was  in  eight  days — in  Cazaban's  case.  In  one  case  the  fistula  remained  open  seven 
and  one-half  months.  Gauderon  said  that,  on  an  average,  the  fistula  closed  in  a 
month. 

In  a  few  cases  the  umbilical  swelling  was  incised  before  it  had  time  to  rupture, 
thus  facilitating  the  escape  of  the  pus. 

Complications.  — -In  Triboulet's  case  a  friction-rub  developed  at  the 
base  of  the  right  lung.  In  West's  case  there  was  a  purulent  pleurisy  with  effusion, 
and  in  Baizeau's  case  a  pleuropneumonia  developed. 

Recovery.  —  As  pointed  out  by  Gauderon,  nearly  all  the  children  in 
whose  cases  the  peritonitis  opened  at  the  umbilicus  recovered.  Those  dying  suc- 
cumbed to  lesions  in  no  way  dependent  on  the  peritonitis. 

Causes  of  the  Peritonitis. 
These  cases  have  usually  been  spoken  of  as  instances  of  idiopathic  peritonitis, 
and  as  most  of  the  reported  cases  occurred  before  bacteriologic  examinations  were 
made,  we  have  no  way  of  determining  absolutely  their  mode  of  origin.  According 
to  Ledderhose,  Henoch's  patient  had  been  trampled  on  by  a  large  dog  and  the  peri- 
tonitis had  soon  followed.  Cameron's  Case  VI,  reported  in  1912,  was  due  to  the 
pneumococcus,  and  in  his  Case  VII  there  was  probably  a  similar  origin.  From  a 
careful  study  of  these  cases  one  gathers  the  impression  that  the  pneumococcus  may 
be  responsible  for  the  majority  of  the  cases  of  so-called  idiopathic  peritonitis. 


300  THE    UMBILICUS   AND    ITS    DISEASES. 

Differential  Diagnosis. 
These  cases  of  peritonitis  are  occasionally  simulated  by  deep-seated  inflamma- 
tions between  the  umbilicus  and  pubes.  These  are  usually  due  to  an  infection  of 
remnants  of  the  urachus.  If  the  inflammation  occurs  in  young  children,  for  the 
first  few  days  it  may  be  impossible  to  differentiate  between  it  and  a  general  peri- 
tonitis, the  symptoms  being  identical  (p.  567),  but  after  an  interval  of  four  to  five 
days  the  abdominal  swelling  diminishes,  the  abdomen  becomes  flat,  and  a  localized 
tumor  is  felt  between  the  umbilicus  and  pubes,  whereas  in  a  peritonitis  the  intra- 
abdominal fluid  is  still  evident. 

Cases  of  General  Peritonitis  Opening  at  the  Umbilicus. 

These  cases  are  of  interest  from  a  historic  standpoint,  showing,  as  they  do,  how 
nature  may  liberate  a  purulent  peritoneal  accumulation.  In  the  future  we  shall 
expect  to  see  still  fewer  of  these  cases,  since,  with  the  operative  facilities  that  we 
now  possess,  abdominal  drainage  will  be  adopted  early  in  the  disease. 

Purulent  Peritonitis  with  Spontaneous  Evacuation 
Through  the  Umbilicus;  Healing.*  —  A  girl,  aged  seven  years 
and  four  months,  was  visited  by  Dr.  Aldis  on  June  5,  1846.  She  lay  on  her  right 
side;  the  face  was  emaciated  and  drawn,  and  the  expression  was  anxious.  The 
extremities  were  atrophied.  The  urine  was  scanty,  the  abdomen  was  distended, 
and  there  was  a  projection  at  the  umbilicus ;  fluctuation  was  manifest.  About  eleven 
weeks  before,  the  child  had  been  seized  with  chills  and  fever,  vomiting,  and  pain  in 
the  abdomen;  on  the  following  day  she  was  delirious.  An  examination  of  the 
abdomen  failed  to  reveal  any  induration.  On  June  7th  an  opening  occurred  spon- 
taneously in  the  tumor,  and  over  2000  c.c.  of  purulent  material  escaped  from  the 
abdomen.  The  child  complained  of  pain  in  the  hips.  The  urine  was  abundant  and 
pale.  On  the  following  days  pus  continued  to  escape.  On  June  12th  the  abdomen 
was  perfectly  flat,  and  the  child  was  visited  for  the  last  time.  On  September  30th 
she  was  in  good  condition.  The  abdominal  girth  was  only  20  inches  in  the  region  of 
the  umbilicus,  and  the  opening  was  closed  by  a  solid  cicatrix. 

Probably  a  Peritonitis,  with  Escape  of  Pus  From 
the  Umbilicus.  — Bricheteauf  reported  a  case  in  which  a  large  abscess  of  the 
abdomen,  simulating  an  acute  peritonitis,  opened  at  the  umbilicus.  A  girl,  aged 
seventeen,  of  lymphatic  constitution,  on  May  17,  1839,  complained  of  abdominal 
pain.  The  abdomen  was  sensitive,  and  she  could  not  bear  to  be  touched  with  the 
hand.  The  skin  was  hot,  the  pulse  somewhat  accelerated.  There  was  very  fre- 
quent vomiting.  The  expression  was  anxious,  but  the  general  abdominal  contour 
was  not  altered.  Prolonged  baths  were  given,  but  eight  or  ten  days  later  the 
abdominal  pain  returned  and  was  associated  with  tension.  The  patient  could 
not  sit  up.  Vomiting  reappeared  and  there  was  diarrhea.  Thirst  was  marked, 
and  there  was  much  heat  of  the  skin  and  an  increase  of  fever.  The  abdomen  was 
distended  and  tympanitic  on  the  left  side,  and  the  patient  lay  continuously  on 
her  right  side.     On  June  12th  Bricheteau  noted  that  the  skin  of  the  umbilicus 

*  Aldis:  Gaz.  med.  de  Paris,  1848,  733.  Cited  by  Gauderon:  De  la  pcritonite  idiopath- 
ique  aigue  des  enfants;  de  sa  terminaison  par  suppuration  et  par  evacuation  du  pus  a  travers  l'om- 
bilic.     These  de  Paris,  1876,  No.  148;  obs.  25. 

t  Bricheteau:  Des  abces  dans  le  tissu  cellulaire  sous-peritoneal.  Arch.  gen.  de  med.,  1839, 
vi,  435. 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  301 

was  thin  and  raised,  and  two  days  later,  on  removal  of  a  poultice,  a  jet  of  pus  was 
seen  escaping  from  the  umbilicus  and  an  enormous  quantity  came  away.  It  was 
thick  in  consistence,  without  odor,  and  resembled  the  serous  pus  of  peritonitis. 
The  suppuration  continued  for  several  days,  after  which  the  opening  closed.  It 
opened  again  and  finally  closed  permanently.  The  patient  for  a  long  period  had 
digestive  troubles  with  vomiting,  and  was  not  permanently  cured  until  after  a 
sojourn  of  three  months  in  the  country. 

Purulent  Peritonitis;  Spontaneous  Rupture  at  the 
Umbilicus;  Abscess  of  the  Parotid;  Pleurisy;  Recov- 
ery.* — ■  The  patient  was  a  boy,  twelve  years  of  age,  in  good  health  and  of  a 
strong  constitution.  Suddenly  he  complained  of  pain  in  the  abdomen  and  fever  de- 
veloped. The  abdomen  became  distended,  ballooned  out,  and  was  very  sensitive. 
The  slightest  pressure  could  not  be  made  except  near  the  hypogastrium.  The  facial 
expression  was  altered.  The  radial  pulse  was  110.  The  skin  was  burning.  There 
was  excessive  thirst  and  incessant  vomiting.  The  diagnosis  did  not  offer  any  dif- 
ficulties, but  the  cause  of  the  peritonitis  was  not  easy  to  determine.  He  showed  no 
signs  of  external  violence,  and  nothing  indicating  intestinal  perforation.  Twenty 
leeches  were  applied  to  the  abdomen  and  were  then  replaced  by  fomentations. 
The  abdomen  had  diminished  in  size  by  the  next  day,  except  in  the  region  of  the 
umbilicus,  where  the  swelling  had  increased.  The  general  condition  remained  the 
same;  the  fever  and  vomiting  continued.  Applications  of  leeches  were  again  made. 
On  the  fifteenth  day  there  was  some  improvement.  The  abdomen  remained  dis- 
tended, but  was  less  sensitive  on  pressure.  The  pulse  was  100;  the  vomiting  had 
ceased.  There  had  been  no  movement  of  the  bowels  for  two  days.  On  the  eigh- 
teenth day  there  was  a  marked  change.  After  dinner  an  intense  pain  developed  in 
the  right  hypochondriac  region,  reaching  to  the  shoulder.  The  child  cried,  and 
the  suffering  was  extreme.  The  vomiting  returned,  and  the  pulse  reached  115. 
A  right  pleuropneumonia  developed.  The  point  of  greatest  intensity  was  at  the 
right  nipple.  This  new  affection  progressed.  On  March  15th  pain  was  noted  in 
the  right  parotid  region  and  a  large  parotid  abscess  was  opened.  About  March 
20th  the  abdominal  pain  reappeared  without  appreciable  cause.  It  was  easily 
possible  to  make  out  an  abundant  quantity  of  fluid  in  the  peritoneum.  The  umbil- 
icus was  pushed  out  by  the  fluid,  and  formed  a  small  external  tumor.  On  April  2d 
this  broke,  and  several  liters  of  greenish  pus  with  thick,  grumous  material  escaped. 
The  discharge  lasted  for  several  days  and  improvement  was  noted.  A  drainage- 
tube  was  introduced,  and  an  injection  of  lukewarm  water  made.  The  suppuration 
diminished.  At  the  same  time,  in  the  right  nipple  region,  a  fluctuating  tumor  was 
punctured.  On  April  10th  about  six  quarts  of  pus  escaped  from  the  umbilicus. 
Toward  the  end  of  May  the  thoracic  fistula  closed.  About  June  21st  there  was 
severe  pain  in  the  region  of  the  right  shoulder,  reaching  to  the  lung,  and  accom- 
panied by  intense  fever.  In  the  course  of  several  days  a  fluctuating  tumor  was 
detected,  and  on  puncture  an  abundance  of  pus  escaped.  A  drainage-tube  was 
introduced  and  an  injection  of  iodin  was  employed.  The  chest  fistula  closed  on 
October  1st;  that  of  the  abdomen,  on  December  20th.  The  abdomen  was  soft  and 
pliable.     The  respirations  were  normal. 

*  Baizeau:  Arch.  gen.  de  med.,  1875,  163.  Quoted  by  Gauderon,  A.  E.:  De  la  peritonite 
idiopathique  aigue  des  enfants;  de  sa  terminaison  par  suppuration  et  par  evacuation  du  pus  a 
travers  l'ombilic.     These  de  Paris,  1876,  No.  148,  observation  xx. 


302  THE    UMBILICUS    AND    ITS    DISEASES. 

Purulent  Peritonitis;  Spontaneous  Opening  at  the 
Umbilicus.*- —  The  subject  of  this  observation  was  a  young  girl  of  ten  who 
had  a  good  constitution  and  had  previously  been  well.  For  a  month  preceding  her 
illness  she  had  spent  her  time  quietly  with  her  parents.  On  May  31,  1872,  she  had 
constant  pain  in  the  abdomen,  accompanied  by  nausea  and  vomiting.  The  eyes 
were  sunken  and  the  face  was  drawn.  There  were  several  liquid  stools,  and  the 
patient  had  cramps  in  the  legs.  The  case  suggested  cholera.  On  the  following 
day,  at  9  a.  m.,  the  vomiting,  which  had  been  frequent  during  the  night,  stopped. 
The  patient  commenced  to  complain  of  pain  in  the  head.  This  became  more  and 
more  violent,  and  was  accompanied  by  delirium.  Ice  was  applied  to  the  head. 
The  cerebral  trouble  for  some  time  completely  overshadowed  the  lesion  in  the 
abdomen.  The  delirium  disappeared  in  the  course  of  four  or  five  days,  but  the 
fever  continued.  There  was  great  thirst,  and  the  tongue  was  covered  with  sordes. 
The  abdomen  was  also  painful  and  distended,  and  a  certain  amount  of  fluid  could 
be  detected  in  the  peritoneal  cavity.  On  the  following  day  the  pain  was  referred 
principally  to  the  right  hypochondriac  region,  and  some  complication  in  the  liver 
was  thought  of.  The  child  complained  continually  of  suffocation  and  palpitation 
of  the  heart.  The  abdomen  increased  in  size,  and  was  in  marked  contrast  to  the 
extremities,  which  were  greatly  emaciated.  This  condition  persisted  for  a  month 
without  any  amelioration.  The  digestive  troubles  were  more  and  more  pronounced; 
very  frequently  there  was  vomiting  of  bile  and  a  diarrhea.  For  some  unknown  rea- 
son a  plaster  was  applied  to  the  abdomen,  and  when  it  was  drawn  back  in  one  of  the 
early  days  in  July,  it  was  noted  that  the  umbilicus  was  distended  by  the  abdominal 
fluid.  It  was  red  and  very  thin  in  its  center.  On  the  following  clay  it  opened  spon- 
taneously, and  about  4  liters  of  purulent,  greenish  fluid  escaped.  The  discharge  con- 
tinued that  night  and  for  several  days  in  great  abundance.  The  child  felt  relieved  and 
slept;  the  appetite  returned,  and  there  was  a  marked  change  for  the  better.  This, 
however,  did  not  last;  the  fever  returned,  the  nights  were  bad,  and  the  digestion 
again  became  disordered.  Baizeau  was  called  in  consultation  on  July  14th.  He 
found  the  infant  very  much  emaciated  and  feeble,  and  with  a  continuous  fever. 
The  abdomen  was  markedly  distended,  and  there  was  an  escape  of  grayish,  thick 
pus,  with  a  strong  odor,  and  containing  greenish  streaks  indicating  its  hepatic  origin. 
This  greenish  material,  which  escaped  in  large  quantities,  yielded  biliverdin.  The 
abdomen  was  painful,  and  at  times  the  child  complained  of  severe  pain.  The  pus 
was  secreted  by  the  peritoneum  and  escaped  incompletely.  The  umbilical  opening 
was  too  narrow  for  the  introduction  of  a  drainage-tube.  The  orifice  was  dilated 
with  rubber,  and  on  the  third  day  a  drain  was  introduced.  Injections  were  made 
morning  and  evening  with  tepid  water,  and  the  fluid  appeared  to  pass  into  all  parts 
of  the  abdomen.  The  fever  ceased,  and  a  verj^  favorable  change  in  the  general 
condition  was  noted.  The  activity  of  the  stomach  returned,  and  the  child,  who 
had  been  fretful  and  depressed,  became  lively.  The  abdomen  was  more  supple 
and  less  painful.  Suppuration  stopped,  and  the  drainage-tube  was  taken  out  on 
August  28th.  Three  days  later  the  umbilicus  was  completely  closed.  The  child 
had  not  completely  recovered  her  usual  buoyancy,  but  the  general  condition  was 
markedly  improved.  The  abdomen  was  supple  and  looked  normal.  The  abnormal 
sensibility  had  entirely  disappeared,  and  the  digestive  functions  were  regular. 
About  September  loth  she  left  Algiers  for  Paris,  where  she  continued  to  improve. 
*  Baizeau:  Quoted  by  Gauderon,  op.  cit.,  obs.  22. 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  303 

Purulent  Peritonitis;  Escape  of  Pus  at  the  Umbili- 
cus; Persistence  of  the  Umbilical  Hernia;  Healing.*  — 
The  patient  was  a  child  of  five  years  who  had  been  healthy.  On  January  4th  the 
child  presented  symptoms  of  catarrhal  fever.  On  January  6th  signs  of  peritonitis 
had  developed.  Under  treatment  the  fever  diminished,  but  the  abdomen  was  pain- 
ful and  much  distended.  Percussion  showed  that  the  distention  was  not  due  to 
the  presence  of  air  in  the  intestine,  but  to  an  effusion  of  fluid  in  the  peritoneal  cavity. 
The  child  refused  absolutely  to  take  medicine.  On  January  22d  the  umbilicus 
was  prominent,  semitransparent,  and  red.  By  the  following  day  the  tumor  had 
increased  in  size  to  that  of  a  hen's  egg,  and  the  skin  had  become  thinner.  The 
presence  of  fluid  could  be  distinctly  made  out.  On  January  25th  the  tumor  ruptured 
and  fluid  escaped  in  a  stream  the  size  of  a  goose-quill.  The  fluid  was  semipurulent  ; 
about  enough  to  fill  a  "bottle  and  a  half"  came  away.  On  the  following  day  the 
discharge  was  moderate  in  amount  and  the  abdomen  was  sensitive.  The  febrile 
symptoms  did  not  disappear.  About  February  12th  the  condition  of  the  patient 
commenced  to  improve,  but  the  umbilical  fistula  still  persisted.  Dr.  Beonhardy 
attended  the  patient  until  September  15th.  At  that  time  the  fistula  had  closed, 
but  the  child  still  continued  to  wear  a  bandage  on  account  of  the  umbilical  hernia. 
The  destruction  of  the  cellular  tissue  closing  the  umbilicus  had  favored  the  produc- 
tion of  a  hernia. 

Pneumococcal  Peritonitis  Present  at  Umbilicus. f 
— Case  VI. — A  girl,  aged  five  years,  was  admitted  on  April  5,  1911.  Six  weeks  be- 
fore, she  had  had  an  acute  illness.  At  first  appendicitis  had  been  diagnosed,  and 
later  pneumonia.  After  a  week  the  abdominal  pain  had  disappeared,  but  the 
child  had  remained  without  appetite.  Before  admission  the  presence  of  free  fluid 
in  the  abdominal  cavity  had  been  recognized.  A  diagnosis  of  tuberculous  peri- 
tonitis was  made,  and  the  child  was  kept  out-of-doors.  The  opsonic  index  to 
tuberculosis  was  1.2.  On  April  30th  a  swelling  appeared  at  the  umbilicus  and 
became  so  prominent  that  it  was  decided  to  operate.  As  soon  as  the  peritoneum 
was  opened  pus  poured  out,  three  pints  being  collected.  A  pure  growth  of  pneumo- 
coccus  was  obtained.  Recovery  followed,  and  the  child  was  discharged  well  on 
July  8th. 

Probable  Pneumococcal  Peritonitis  Opening  at  the 
Umbilicus. ±  —  Case  VII. — -A  girl,  aged  eight,  was  admitted  July  9,  1903, 
under  Dr.  Taylor's  care.  On  April  20th  she  had  suddenly  complained  of  abdominal 
pain,  and  an  acute  illness  of  many  weeks'  duration  had  followed.  It  was  supposed 
to  be  typhoid  fever.  In  the  fourth  week  she  was  still  ill.  On  July  7  Dr.  Taylor  saw 
the  child  and  admitted  her  to  the  hospital.  The  abdomen  was  swollen  and  con- 
tained fluid.  On  the  day  before  her  admission  a  fistula  formed  at  the  umbilicus. 
Mr.  Lane  operated,  and  one  and  one-half  pints  of  greenish-yellow  pus  escaped. 
The  child  recovered  and  was  discharged  September  3,  1903.  When  heard  from  in 
March,  1905,  she  was  well. 

Abdominal  Abscess  Simulating  Ascites;  Sponta- 
neous   Opening    at  the  Umbilicus.     Recovery. §  —  A  girl,  five 

*  Beonhardy:  Brit,  and  For.  Med.  Rev.,  xiv,  549.     (Cited  by  Gauderon,  op.  cit.) 

f  Cameron,  Hector  Charles:  The  Relative  Value  of  Immediate  and  Delayed  Laparotomy  in 
Pneumococcal  Peritonitis.     Proc.  Roy.  Soc.  Med.,  February,  1912,  v,  Xo.  4,  123. 

±  Cameron,  H.  C:   Op.  cit. 

§  Cazaban:  Abces  abdominale  simulant  une  ascite;  ouverture  spontanee  par  le  nombril; 
guerison.     Jour,  de  chirurgie,  1845,  iii,  252. 


304  THE    UMBILICUS    AND    ITS    DISEASES. 

years  old,  of  weak  constitution,  was  suddenly  seized  with  pain  in  the  abdomen. 
The  bowels  did  not  move,  but  blood  and  mucus  escaped  by  the  rectum.  The  pulse 
was  rapid  and  small,  the  tongue  red,  the  skin  hot,  and  there  was  pain  on  pressure, 
chiefly  in  the  hypogastric  region.  On  her  way  to  the  hospital  there  were  several 
inclinations  to  stool,  but  only  tenesmus  resulted.  This  condition  kept  up  for  eight 
or  ten  days.  The  symptoms  of  dysentery  disappeared,  but  the  abdomen  was  pain- 
ful and  the  fever  persisted.  The  child  appeared  to  suffer  less  and  seemed  to  be 
improving,  but  the  abdomen  remained  sore.  Local  applications  were  used,  but 
during  September  the  child  grew  thinner,  and  the  abdomen  continued  to  distend. 
In  October  the  abdomen  was  much  larger  and  was  oval  in  form. 

It  was  decided  to  puncture,  but  this  procedure  was  delayed  five  or  six  days. 
Meanwhile  a  phlegmonous  erysipelas  developed  at  the  umbilicus.  The  cicatrix 
became  prominent,  and  finally,  in  one  day,  more  than  four  liters  of  whitish-yellow, 
creamy  but  odorless  pus  escaped  from  the  umbilicus.  The  abdomen  still  remained 
painful  after  the  fluid  came  away.  Eight  days  later  the  umbilical  opening  had 
closed  completely,  the  fever  was  gone,  and  the  child  was  convalescing;  in  one  month 
she  was  perfectly  well. 

Peritonitis  with  Escape  of  Pus  from  the  Umbilicus.* 
—  This  case  was  observed  in  the  service  of  Triboulet.  Maria  M.,  aged  six  and 
one-half  years,  entered  the  hospital  on  April  29,  1874.  Without  apparent  cause  she 
had  become  seriously  ill  on  April  18th.  At  the  beginning  there  had  been  pain  in  the 
abdomen  and  excessive  vomiting,  which  had  lasted  for  twenty-four  hours.  For 
several  days  there  had  been  some  ten  diarrheal  stools  daily,  but  without  a  trace  of 
blood  or  pus.  The  diarrhea  had  not  disappeared  entirely  when  the  child  entered 
the  hospital.  She  had  high  fever,  and  lay  immobile  in  her  bed.  Applications  were 
made  to  the  abdomen.  On  April  26th  a  small,  elevated  tumor  was  noted  at  the 
umbilicus,  and  when  he  saw  her,  on  April  28th,  the  physician  made  a  diagnosis  of 
umbilical  hernia.  On  admission  to  the  hospital  an  attempt  was  made  to  reduce 
the  supposed  hernia.  There  were  also  signs  of  some  thoracic  affection.  She  was 
transferred  to  Triboulet's  service.  The  facial  expression  was  that  of  peritonitis — 
the  eyes  were  sunken,  the  facial  lines  drawn;  the  respirations  were  32  to  the  minute. 
Percussion  of  the  lungs  was  negative,  but  a  friction-rub  could  be  heard  at  the  base 
of  the  right  lung  and  in  front.  The  pulse  was  140,  the  skin  moderately  hot.  On 
April  30th  signs  of  peritonitis  still  persisted.  The  tongue  was  red,  and  its  epi- 
thelium was  dropping  off.  There  was  an  escape  in  a  jet  of  about  1500  c.c.  of  a 
yellowish,  odorless  pus  from  the  umbilicus.  After  the  flow  ceased,  the  umbilical 
cicatrix  could  be  made  out;  it  was  distended  and  indurated,  and  at  the  top  was 
a  small  orifice  from  which  the  pus  had  escaped.  The  child  had  some  diarrhea 
after  this,  but  no  vomiting,  nausea,  or  hiccups.  By  the  same  evening  the  facial 
expression  had  become  better,  and  by  the  next  morning  the  child  wanted  something 
to  eat.  There  was  no  vomiting,  and  not  the  slightest  trace  of  pus  by  bowel.  A 
moderate  amount  of  discharge  still  issued  from  the  umbilicus.  On  May  3d  a 
certain  quantity  of  pus  escaped.  By  the  following  day  the  diarrhea  had  ceased 
completely,  and  on  June  1  the  child  was  taken  to  a  convalescent  home.  She  was 
completely  cured,  and  the  umbilical  fistula  had  closed.  At  no  point  in  the 
abdominal  wall  was  there  any  trace  of  induration. 

*  Gauderon:    Op.  cit. 


THE    ESCAPE    OF    FLUID    FROM   THE    UMBILICUS.  305 

General  Peritonitis  Cured  by  Incision  of  the  Pro- 
truding Umbilicus.  —  Under  date  of  June  3,  1910,  Dr.  W.  D.  Haggard, 
of  Nashville,  Tenn.,  wrote  me  concerning  the  history  of  a  patient  suffering  from 
general  peritonitis.  The  fluid  had  been  evacuated  through  an  incision  into  the 
protruding  umbilicus.  The  patient  was  a  girl  twelve  years  old.  She  had  had  a 
violent  attack  of  appendicitis  with  great  initial  prostration.  At  the  end  of  three 
weeks  she  had  improved  considerably,  but  the  temperature  would  reach  100°  F. 
m  the  afternoon,  and  the  abdomen,  which  had  originally  been  hard  and  distended, 
was  now  soft  and  fluctuating,  and  showed  a  protruding,  red,  and  thinned-out 
umbilicus.  This  was  incised  under  ethyl  chloricl  inhalation,  and  fully  three  quarts 
of  purulent  fluid  were  evacuated.  The  umbilicus  had  to  be  reopened  on  account 
of  an  accumulation  of  a  small  quantity  of  fluid.  Dr.  Haggard  told  me  that  the 
patient  was  well  two  months  later,  but  that  an  interval  removal  of  the  appendix 
had  been  advised. 

Peritonitis  with  the  Escape  of  Pus  From  the  Umbili- 
cus. —  Ledderhose*  says  that  Henoch  described  in  his  text-book  the  case  of  a 
girl,  ten  years  old,  who,  after  having  been  trampled  upon  by  a  large  dog,  had  acute 
peritonitis  which  terminated  by  a  breaking  through  at  the  umbilicus.  Ledderhose 
adds  that  in  grown  people  acute  peritonitis  has  no  tendency  to  break  through  at  the 
umbilicus. 

Purulent  Peritonitis  Following  Scarlatina  in  an 
Infant  Thirteen  Months  Old.f  —  This  was  the  case  reported  by  Dr. 
West. J  A  small,  well-nourished  girl  had  scarlet  fever  when  eight  months  old. 
The  eruption  was  not  marked,  but  after  its  disappearance  the  child  did  not  recover 
her  health,  continued  to  be  restless,  and  had  fever.  Sometimes  she  would  vomit, 
and  the  eyelids  at  times  were  swollen.  Fifteen  days  after  the  appearance  of  the 
eruption  she  had  two  violent  attacks  of  convulsions.  She  remained  sick  until  she 
was  ten  and  a  half  months  old,  when  her  mother  noticed  puffiness  of  the  eyelids 
and  swelling  of  the  legs  and  of  the  abdomen.  When  the  child  came  under  West's 
observation  there  were  still  edema  of  the  legs  and  distinct  fluctuation  in  the 
abdomen.  The  urine  was  scanty  and  showed  some  pathologic  changes.  Three 
weeks  later  her  general  condition  was  considerably  improved.  The  urinary  secre- 
tion was  more  abundant,  and  the  abdominal  circumference  was  4  cm.  less  than 
before.  She  had  an  attack  of  convulsions  without  any  apparent  cause.  For  a 
week  seropurulent  material  escaped  at  the  umbilicus  and  continued  to  do  so,  the 
amount  varying  from  150  to  200  c.c.  This  event  was  followed  by  improvement 
in  the  patient's  condition,  but  after  eleven  days  the  fever  and  dyspnea  increased 
and  there  was  a  dulness  on  percussion  over  the  right  lung  and  absence  of  the 
respiratory  murmur  in  front.  The  discharge  ceased  for  a  week,  at  the  time  that 
the  thoracic  symptoms  were  most  intense.  Afterward  there  was  again  some  dis- 
charge which  was  small  in  amount.  The  child  at  this  time  was  very  feeble  and 
much  emaciated.  She  was  given  stimulants,  but  forty-eight  hours  later  died  with- 
out any  signs  of  convulsions,  just  five  and  a  half  months  after  the  scarlet  fever 
and  two  months  after  coming  under  observation.     At  autopsy  a  purulent  pleurisy 

*  Ledderhose,  G. :  Deutsche  Chirurgie,  1890,  Lief.  45  b,  122. 

t  Gauderon  (West):  Op.  cit.,  obs.  23. 

X  West,  Charles:  Lectures  on  the  Diseases  of  Infancy  and  Childhood.     Fifth  Am.  Ed.,  Phila., 
1874,  107. 

21 


306  THE    UMBILICUS    AND    ITS    DISEASES. 

was  found  on  the  right  side  and  an  effusion  of  about  180  c.c.  of  pus  in  the  right 
pleural  cavity.     About  1250  c.c.  of  a  similar  liquid  was  found  in  the  abdomen. 

Umbilical  Abscess  Following  General  Peritonitis.  — 
Gauderon*  gives  the  abstract  of  a  case  published  by  Vetu  in  the  Jour,  de  msd., 
chir.,  pharmacie  et  de  med.  veterinaire  de  la  Cote  d'Or,  1846.  The  patient  was  a 
small  girl  of  four  years  who  was  convalescing  from  acute  peritonitis.  A  tumor  the 
size  of  an  almond  was  noted  in  the  umbilical  region  on  May  14th.  This  was  soft 
and  elastic,  and  there  was  no  change  in  color  in  the  skin.  It  was  depressible,  and 
when  it  had  disappeared,  in  the  depression  the  finger  could  make  out  clearly  the 
hernial  ring,  but  when  the  pressure  was  released,  the  tumor  reproduced  itself. 
When  the  child  cried  or  moved  about,  it  became  prominent.  Vetu  diagnosed  the 
condition  without  hesitation  as  an  umbilical  hernia.  On  May  18th  the  tumor  was 
larger,  being  the  size  of  an  elongated  walnut.  Vetu  did  not  notice  anything  extra- 
ordinary in  the  aspect  of  the  abdomen.  Applications  were  made  to  the  abdomen, 
and  on  May  22d,  four  days  later,  the  physician  was  not  a  little  surprised  to  find  the 
child  literally  bathed  in  creamy  pus.  On  removal  of  the  dressing,  it  was  found  that 
the  tumor  had  disappeared  and  that  pus  was  escaping  from  the  umbilicus,  the  total 
amount  being  estimated  as  1500  to  2000  c.c.  After  the  pus  had  stopped  running, 
an  opening  which  admitted  the  extremity  of  the  finger  was  noted  at  the  umbilicus. 
There  was  not  a  trace  of  hernia.  In  the  course  of  ten  days  the  ring  was  completely 
closed  and  the  child  recovered. 


LITERATURE  CONSULTED  ON  PERITONITIS  WITH  THE  ESCAPE  OF  PUS  AT  THE 

UMBILICUS. 
Aldis:  Gaz.  med.  de  Paris,  1848,  733. 
Baizeau:  Arch.  gen.  demed.,  1875,  163. 

Bricheteau:   Des  abces  dans  le  tissu  cellulaire  sous-peritoneal.     Arch.  gen.  de  med.,  1839,  vi,  435. 
Cameron,  H.  C. :    The  Relative  Value  of  Immediate  and  Delayed  Laparotomy  in  Pneumococcal 

Peritonitis.     Proc.  Roy.  Soc.  London,  February,  1912,  v,  No.  4,  123. 
Castel,  J.:    Considerations  sur  la  pathogenie  des  fistules  ombilicales.     These  de  Paris,  1884,  No. 

56. 
Cazaban:   Abces  abdominal  simulant  une  ascite;    ouverture  spontanee  par  le  nombril;    guerison. 

Jour,  de  chir.,  1845,  hi,  252. 
Gauderon,  A.  E. :   De  la  peritonite  idiopathique  aigue  des  enfants;  de  sa  terminaison  par  suppura- 
tion et  par  evacuation  du  pus  a.  travers  l'ombilic.     These  de  Paris,  1876,  148. 
Haggard,  W.  D.:    General  Peritonitis  Cured  by  Incision  of  the  Protruding  Umbilicus  (personal 

communication). 
Ledderhose,  G.:    Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Nicaise:    Ombilic.     Dictionnaire  encyclopedique  des  sciences  medicales,  Paris,  1881,  2.  ser.,  xv, 

140. 
Vaussy,  F.:   Des  phlegmons  sous-peritoneaux  de  la  paroi  abdominale  anterieure.     These  de  Paris, 

1875,  No.  445. 


THE  PIECEMEAL  REMOVAL  OF  A  SUPPURATING  OVARIAN  CYST  THROUGH 

THE  UMBILICUS. 

From  the  following  history  it  is  clearly  evident  that  the  patient  had  an  ovarian 
cyst.  The  suppuration  was,  no  doubt,  in  a  measure  due  to  infection  following  the 
last  abdominal  puncture,  and  it  is  remarkable  that  the  patient  recovered.  The 
woman  came  under  observation  over  thirty  years  ago  at  a  period  when  one  hesi- 

*  Gauderon:   Op.  cit.,  obs.  17. 


THE    ESCAPE    OF    FLUID    FROM    THE    UMBILICUS.  307 

tated  a  long  time  before  opening  the  abdomen.     Now,  of  course,  the  cyst  would  be 
promptly  removed. 

Inflammation  of  an  Ovarian  Cyst,  Abscess  Forma- 
tion, Opening  at  the  Umbilicus.  Recovery.*  —  Madame 
F.,  aged  forty-seven,  was  the  mother  of  several  children.  When  examined  on 
September  10,  1878,  she  had  signs  and  symptoms  of  an  ovarian  cyst  of  three  years' 
duration.  Between  September  10,  1878,  and  November  20,  1879,  the  abdomen  was 
punctured  11  times  and  170  liters  of  a  clear,  serous  fluid  were  removed.  Shortly 
afterward  there  were  signs  of  acute  inflammation  in  the  abdomen,  distention,  high 
fever,  a  small  pulse,  vomiting,  and  the  characteristic  facial  expression.  It  was 
thought  that  she  would  die.  Four  days  later  the  patient  was  still  alive,  and  redness 
was  noted  at  the  umbilicus  over  an  area  3  by  4  cm.  In  six  days  there  were  signs 
of  fluctuation,  and  three  days  later  between  two  and  three  liters  of  pus  came  away 
from  the  umbilicus.  Trepan  pulled  out  and  cut  off  with  the  scissors  a  large  amount 
of  necrotic  tissue.  About  eighteen  months  after  his  first  visit  he  found  the  patient 
perfectly  well  and  she  remained  so. 


LOCALIZED  JAUNDICE  OF  THE  UMBILICUS  IN  THE  PRESENCE  OF  FREE  BILE  IN 

THE  ABDOMINAL  CAVITY. 

In  April,  1915,  Dr.  Joseph  Ransohoff  drew  my  attention  to  a  most  unusual  con- 
dition, namely,  localized  jaundice  at  the  umbilicus  when  bile  exists  free  in  the 
abdomen. 

In  the  Transactions  of  the  Southern  Surgical  and  Gynecological  Association  for 
1905  Dr.  Ransohoff  reported  the  case  of  W.  B.,  merchant,  fifty-three  years  old, 
who  had  had  typhoid  fever  six  years  before  coming  under  observation.  In  April 
he  had  what  was  supposed  to  be  a  mild  attack  of  indigestion,  and  in  August  was 
seized  with  severe  colicky  pain  in  the  umbilical  region.  The  pain  disappeared  in  five 
days.  Ransohoff  saw  him  in  October.  The  patient  had  had  a  sudden  chill  during 
the  night ;  he  had  had  pain  in  the  right  hypochondrium,  and  on  the  next  day  had 
complained  of  abdominal  distention  and  excruciating  pain  in  the  right  lower 
abdomen. 

On  admission  to  the  hospital  it  was  noted  that  the  patient  was  a  large-framed 
man,  with  every  indication  of  intestinal  obstruction  from  peritonitis.  He  had  an 
anxious  facial  expression;  the  pulse  was  130;  the  temperature,  100°  F.  Examina- 
tion of  the  abdomen  revealed  extreme  tympany,  with  the  liver  dulness  very  much 
pushed  up  and  reduced  in  area. 

On  inspection  of  the  abdomen  marked  jaundice  at  the  umbilicus  was  noted. 
The  navel  was  of  a  distinct,  saffron-yellow  color,  in  strong  contrast  with  the  skin 
over  the  rest  of  the  abdomen.  There  was  no  evidence  of  jaundice  elsewhere. 
Tenderness  was  extremely  marked  over  McBurney's  point.  It  seemed  probable 
that  a  peritonitis  was  present  in  the  appendicular  region.  At  operation  the  sub- 
peritoneal fat  was  found  to  be  yellow,  and  when  the  abdomen  was  opened,  a  quart 
or  more  of  bile  mixed  with  serum  was  found.  The  common  duct  was  ruptured 
behind  the  gastrohepatic  ligament,  the  opening  being  large  enough  to  admit  the 

*  Trepan:  Kyste  del'ovaire;  inflammation  des  parois  et  issue  des  membranes  par  l'ouverture 
ombilicale;   guerison.     Gaz.  med.  de  Picardie,  Amiens,  1883-84,  ii,  16S. 


308  THE    UMBILICUS    AND    ITS    DISEASES. 

tip  of  a  finger.     After  removal  of  the  abdominal  fluid  and  draining  of  the  common 
duct  the  man  made  a  good  recovery. 

Dr.  Ransohoff,  after  reviewing  the  case,  says:  "I  wish  here  to  call  attention  to 
a  sign  which  was  adverted  to  in  the  case  of  ruptured  duct  before  the  incision  was 
made,  and  one  to  which  I  believe  attention  has  never  before  been  directed.  It  is 
the  localized  jaundice  of  the  umbilicus.  Although  a  single  case  is  not  usually  suffi- 
cient to  warrant  the  assumption  that  something  new  has  been  observed,  this  feature 
was  so  marked  that  I  cannot  refrain  from  believing  that  further  observation  will 
give  to  this  localized  jaundice  some  value  as  a  sign  of  free  bile  in  the  peritoneal 
cavity.  In  the  case  presented  this  feature  gained  in  interest  as  the  staining  of  the 
subperitoneal  fat  with  bile  was  observed  in  the  incision  through  the  abdominal  wall. 
The  jaundice  is  doubtless  purely  the  result  of  imbibition.  It  makes  itself  manifest, 
first,  in  the  integument  of  the  navel,  because  this  part  is  thinner  than  the  rest 
of  the  abdominal  wall.  It  is  possible,  of  course,  that,  by  reason  of  the  anatomic 
relations  of  the  round  ligament  of  the  liver  to  the  transverse  fissure,  there  is  a  retro- 
grade flow  of  bile  through  the  lymphatics  toward  the  navel." 


CHAPTER  XX. 
FECAL  FISTULA  AT  THE  UMBILICUS. 

Historic  sketch. 

Fecal  fistulse  at  the  umbilicus  due  to  wide-spread  ulceration  of  the  large  and  small  intestine. 

Fecal  fistula?  at  the  umbilicus  due  to  gangrene. 

Fecal  fistulse  at  the  umbilicus  due  to  external  injury. 

Umbilical  fecal  fistula?  due  to  burns. 

Tuberculous  peritonitis  followed  by  a  fecal  fistula  at  the  umbilicus;   report  of  cases. 

Umbilical  fistula  (not  fecal)  due  to  tuberculosis  of  the  vas  deferens. 

Umbilical  fistulse  may  be  due  to  a  patent  omphalomesenteric  duct,  to  inflam- 
matory changes  commencing  in  the  intestine  and  extending  to  the  umbilicus,  to 
carcinoma  of  an  abdominal  organ,  usually  of  the  stomach,  reaching  to  and  breaking 
through  the  umbilicus,  to  inflammatory  conditions  of  the  umbilicus  extending  to 
and  involving  the  intestine,  and  to  external  injuries.  All  except  the  last  two  groups 
have  been  dealt  with  elsewhere.  In  the  present  chapter  I  shall  refer  briefly  to 
certain  cases  of  obscure  abdominal  lesions  followed  by  fecal  fistula  at  the  umbilicus, 
and  then  describe  those  cases  in  which  the  fecal  fistula  was  due  to  external  injury 
of  the  umbilicus. 

Le  Cat,  in  1775,  reported  a  case  of  fecal  fistula  at  the  umbilicus.  This  case 
has  also  been  recorded  by  Schrotter.  The  patient  was  a  ten-year-old  girl  who  had 
fecal  masses  escaping  from  the  umbilicus.  For  a  year  before  she  came  under  obser- 
vation the  bowels  had  been  sluggish.  She  had  a  poor  appetite,  associated  with 
abdominal  distention,  and  soon  died.  At  autopsy  the  peritoneum  was  found  to  be 
as  thick  as  a  finger.  The  intestines  were  attached  to  the  anterior  abdominal  wall. 
Below  the  umbilicus  at  one  point  there  was  an  intestinal  perforation,  the  opening 
communicating  with  the  umbilicus.  Between  intestinal  adhesions  there  was  a  con- 
siderable quantity  of  pus  and  fecal  masses,  and  live  lumbricoid  worms  were  seen 
in  the  bowel.  The  mesenteric  glands  were  enlarged,  indurated,  and  suppurating. 
The  intestines  were  ulcerated. 

[At  that  date,  of  course,  no  histologic  examination  was  made.  The  enlarged 
suppurating  glands  would  naturally  suggest  tuberculosis. — T.  S.  C] 

Winiwarter,  in  1877,  recorded  a  case  of  fecal  fistula  at  the  umbilicus.  A  boy, 
eight  months  old,  had  suffered  from  boils  on  several  occasions.  Fourteen  days  before 
admission  to  the  hospital  two  of  these  had  been  opened.  On  September  20,  1875, 
the  child  looked  badly;  there  was  an  infiltration,  9  cm.  in  diameter,  in  the  umbil- 
ical region.  This  area,  which  was  hard  and  covered  with  reddish,  hot  skin,  formed 
a  conic  tumor  with  the  umbilicus  in  the  center.  Poultices  were  applied,  and  after 
three  days  the  swelling  opened.  On  September  25th  the  opening  was  the  size  of  a 
linseed,  and  from  it  yellowish,  grumous,  intestinal  contents  escaped.  After  this 
nothing  passed  by  the  rectum,  for  a  time  all  the  fecal  contents  being  evacuated 
through  the  umbilicus.     The  child  died  on  October  25th.     At  autopsy  a  localized 

309 


310  THE    UMBILICUS    AND    ITS   DISEASES. 

peritonitis  was  noted  at  the  umbilicus.  Beneath  the  umbilicus  was  a  hole,  the  walls 
of  which  were  composed  of  intestinal  loops.     The  fecal  opening  was  in  the  colon. 

As  a  possible  cause,  Winiwarter  considered  phlegmon  of  the  abdominal  wall. 
This,  he  said,  might  have  tended  to  a  localized  peritonitis  causing  adhesions  of 
intestinal  loops.  He  says  that  an  abscess  in  the  abdominal  wall  may  have  broken 
into  the  abdomen  prior  to  opening  externally;  the  large  bowel  might  thus  have 
opened  into  the  abscess  cavity.  Another  explanation  suggested  by  him  was  that 
there  might  have  been  a  primary  enteritis,  and  then  a  peritonitis  with  abscess  forma- 
tion near  the  anterior  abdominal  wall.  No  mention  is  made  of  tuberculosis,  and 
the  fact  that  the  opening  was  in  the  colon  would  suggest  that  the  original  cause 
might  possibly  have  been  appendicitis. 

Trelat,  in  1883,  and  Nicolas  in  the  same  year,  also  report  cases  of  fecal  fistulse. 
Trelat 's  patient  was  a  girl,  seventeen  years  of  age.  When  the  child  was  three 
years  old,  her  mother  noticed  a  swelling  with  redness  and  an  opening  at  the  um- 
bilicus. As  the  wound  would  open  and  close  from  time  to  time,  the  child  wore  a 
bandage.  When  the  umbilicus  first  opened  the  discharge  had  a  fecal  odor.  The 
fistula  was  evidently  of  intestinal  origin.  There  was  no  history  of  any  operation. 
Nicolas'  patient  was  also  seventeen  years  of  age,  and  it  looks  very  much  as  if  Trelat 
and  Nicolas  have  recorded  the  same  case.  In  none  of  these  cases  was  it  possible 
to  determine  the  primary  cause  of  the  umbilical  fistula. 


FECAL  FISTULiE  AT  THE  UMBILICUS  DUE  TO  WIDE-SPREAD  ULCERATION  OF  THE 

LARGE  AND  SMALL  INTESTINE. 

Knecht,  in  1875,  published  the  history  of  a  strongly  built  man,  twenty-nine 
years  old.  In  1873  he  had  had  catarrh  of  the  stomach  which  had  become  chronic, 
and,  as  a  consequence,  he  had  become  anemic  and  had  lost  strength.  After  an 
acute  attack  of  typhlitis  there  was  some  improvement,  but  after  ten  days  the 
symptoms  became  severe  again  and  there  was  a  mild  degree  of  peritonitis.  After 
about  three  months  immediately  beneath  the  umbilicus  there  appeared  a  circum- 
scribed, painful  area  of  infiltration  the  size  of  a  two-thaler  piece.  In  addition  there 
were  several  isolated  areas  of  hardness  in  the  right  inguinal  region  and  also  above 
the  umbilicus.  Some  time  later  an  abscess  in  the  mid-line  opened  and  there  escaped 
a  large  quantity  of  pus  which  had  a  fecal  odor.  After  eight  days  a  new  abscess 
developed  in  the  umbilical  region.  This  opened  spontaneously  into  the  original 
abscess  cavity.  After  about  six  weeks  all  the  abscesses  had  united,  forming  one 
cavity.  The  overlying  skin  sloughed  off,  and  the  abdominal  fascia  lay  free  over 
an  area  the  size  of  the  palm  of  the  hand.  In  the  region  of  the  umbilicus  were 
numerous  openings.  The  patient  died  a  short  while  afterward.  At  autopsy  there 
was  a  marked  degree  of  emaciation  and  edema  of  the  feet,  together  with  much  dis- 
tention of  the  abdomen.  In  the  mid-line  was  an  ulcerated  area,  17  cm.  broad  and 
15  cm.  long.  This  had  raised  and  eaten-out  margins,  and  in  the  center  were  the 
remains  of  the  umbilicus.  In  the  floor  of  the  ulcer  were  openings  with  gangrenous 
walls  which  had  led  to  an  irregular  cavity  through  destruction  of  the  recti.  Pressure 
upon  it  caused  the  escape  of  foul-smelling  bubbles  of  gas.  When  the  abdominal 
cavity  was  opened,  about  10  liters  of  serum  escaped.  The  abdominal  contents 
were  much  displaced.  The  anterior  surface  of  the  cecum,  the  first  fourth  of  the 
transverse  colon,  as  well  as  a  portion  of  the  jejunum,  had  grown  fast  to  the  abdominal 


FECAL    FISTULA    AT    THE    UMBILICUS.  311 

wall  on  the  inner  side  of  the  ulcer,  and  were  also  adherent  to  the  posterior  abdominal 
wall.  The  intestinal  loops  had  grown  fast  to  one  another,  as  well  as  to  the  abdom- 
inal wall.  Just  above  the  ileocecal  valve  the  mucosa  of  the  ileum  contained  several 
ulcers  which  showed  partial  healing.  In  one  of  the  intestinal  loops  adherent  to  the 
anterior  abdominal  wall  was  an  opening  through  which  a  sound  could  be  introduced 
from  the  outside.  In  the  upper  portion  of  the  transverse  colon  were  ulcers  which 
communicated  by  a  perforation  with  the  anterior  abdominal  wall.  There  was  a 
similar  ulcer  in  the  floor  of  the  cecum,  which  communicated  with  a  hole,  lying  behind 
the  abdominal  wall,  and  filled  with  pus  and  necrotic  tissue.  This  cavity  reached  up- 
ward to  the  margin  of  the  kidney  and  extended  along  the  large  vessels.  The  iliacus 
muscle  on  the  right  side  had  disappeared.  In  the  apex  of  the  left  lung  were  several 
scars,  but  no  fresh  tubercles. 

From  the  above  history  it  is  impossible  to  determine  the  exact  starting-point 
of  the  disease.  The  evidence  is,  however,  strongly  suggestive  of  appendicitis  or 
tuberculosis  as  the  exciting  factor. 

The  following  case,  reported  by  Martin,  resembles  in  some  particulars  the  one 
described  by  Knecht: 

Abscess  of  the  Umbilicus;  Gangrene  and  Intestinal 
Perforation;  General  Peritonitis.  Death.  —  This  case  was 
originally  reported  by  Dr.  M.  E.  Martin.*  L.  L.,  aged  seven,  entered  the  hospital  on 
December  27,  1871,  and  died  February  28th  of  the  following  year.  The  child, 
according  to  her  mother,  had  coughed  for  about  a  year,  and  for  the  last  three  months 
a  swelling  had  been  noted  at  the  umbilicus.  From  time  to  time  the  child  had  com- 
plained of  pain,  and  on  her  entrance  to  the  hospital  a  tumor  was  detected  which 
occupied  the  region  of  the  umbilicus.  -This  tumor  was  soft  and  fluctuating  and 
there  was  redness  of  the  skin.  During  January  the  child  showed  a  considerable 
change  for  the  worse,  and  on  palpation  an  accumulation  was  detected  deep  in  the 
abdomen  and  to  the  right  of  the  umbilicus.  On  percussion  dulness  was  noted  over 
this  area.  During  the  process  of  inflammation  the  child  complained  of  pain  in  the 
region  of  the  umbilicus  and  in  the  right  flank.  On  February  13th  there  was  con- 
siderable distention;  pain  was  severe  on  abdominal  pressure,  and  the  child  vomited 
greenish  material.  The  temperature  rose  to  39°  C.,  the  pulse  to  140.  The  vomit- 
ing and  peritonitis  persisted,  accompanied  by  diarrhea  and  greenish  stools,  for  three 
days.  On  January  16th  a  seropurulent  discharge  with  a  definite  fecal  odor  was 
noted  from  an  orifice  immediately  beneath  the  umbilicus.  On  the  seventeenth 
and  eighteenth  there  was  abundant  discharge,  and  on  the  nineteenth  pus,  similar 
in  character  to  that  coming  from  the  umbilicus,  escaped  from  the  rectum.  On 
January  21st  semisolid  fecal  matter  commenced  to  escape  from  the  umbilicus, 
and  the  fistulous  opening  and  the  tissue  around  the  fistulous  opening  began  to 
slough.  On  January  24th  the  area  of  sloughing  had  increased;  the  tongue  was 
covered  with  sordes,  and  the  extremities  were  cold. 

On  the  following  day  the  slough  came  away,  and  on  January  27th  all  fecal  matter 
was  being  passed  by  the  umbilicus.  The  child  became  thinner  and  very  weak,  and 
died  on  February  28th. 

Autopsy. — The  lungs  and  heart  were  normal.  At  the  umbilicus  the  area  of 
sloughing  was  the  size  of  a  five-franc  piece.     The  abdominal  organs  were  bound  to 

*  Martin,  M.  E.:  Abces  de  l'ombilic;  gangrene  et  perforations  intestinales ;  peritonite 
generalisee;  mort.     Bull,  de  la  Soc.  anat.  de  Paris,  1872,  xlvii,  148. 


312  TKE    UMBILICUS    AND    ITS    DISEASES. 

one  another  by  a  false  membrane,  and  the  peritoneum  was  intimately  adherent  to 
the  abdominal  wall  in  the  right  flank.  There  was  an  intestinal  perforation  60  cm. 
from  the  pylorus.  A  portion  of  the  ascending  colon  was  slightly  adherent  to  the 
umbilical  opening,  and  six  other  perforations  were  noted  in  various  portions  of  the 
intestine. 

FECAL  FISTULA  AT  THE  UMBILICUS  DUE  TO  GANGRENE. 

Prior  to  aseptic  days  gangrene  of  the  umbilicus  was  not  infrequently  observed 
in  infants  a  few  days  old  (page  73j.  At  the  present  time  it  is  seldom  seen,  and  in 
the  adult  is  a  rarity.  Ledderhose,  in  1890,  considered  this  subject  somewhat  fully. 
Gangrene  of  the  umbilicus  has  followed  the  continuous  use  of  the  ice-bag,  and  has 
been  associated  with  infectious  diseases  of  the  umbilicus.  Ledderhose  referred  to  a 
case  reported  by  Fischer.  An  ice-bag  was  applied  to  the  abdomen  of  an  anemic 
patient.  Twenty-four  hours  later  the  skin  showed  a  slight  bluish  color,  and  forty- 
eight  hours  later,  after  further  applications  of  ice-bags,  the  tissues  were  deep  blue 
and  there  was  a  sensation  of  burning.  In  the  course  of  three  weeks  150  c.cm.  of 
gangrenous  skin  came  off.  Skin-grafts  were  employed  over  the  raw  area,  and  the 
patient  recovered.     Undoubtedly  the  anemia  favored  the  development  of  gangrene. 

Ledderhose  mentions  two  cases  of  puerperal  infection  under  Thiede's  care. 
Ice-bags  were  kept  on  the  abdomen  for  fifteen  days  in  one  case  and  for  twenty  days 
in  the  other.  Gangrene  of  the  abdominal  wall  developed  in  each  instance.  Thiede 
did  not  think  that  the  ice-bag  was  responsible  for  the  gangrene,  but  that  the  causa- 
tive factor  was  rather  to  be  sought  in  the  squeezing  and  probable  injury  of  the 
abdominal  wall  which  was  produced  every  time  the  uterus  was  emptied  or  washed 
out. 

Ledderhose  further  says  that  gangrene  of  the  umbilicus  may  develop  during  the 
course  of  infectious  diseases  of  the  navel  or  after  exhausting  diseases  involving  the 
stomach  or  intestinal  tract.  Sometimes  only  the  superficial  abdominal  walls  are 
involved;  in  other  cases  the  gangrene  extends  to  the  deeper  layers  of  the  abdominal 
wall  and  leads  to  a  peritonitis  and  perforation  into  the  intestine  or  bladder.  The 
prognosis  is,  in  general,  unfavorable,  but  even  in  severe  cases  recovery  may  ensue. 


FECAL  FISTULA  AT  THE  UMBILICUS  DUE  TO  EXTERNAL  INJURY. 

Fecal  fistula?  as  a  result  of  external  injury  at  the  umbilicus  are  evidently  very 
rare.  Murchison,  in  1858,  recorded  a  very  interesting  case  that  he  saw  with  Keith, 
of  Aberdeen.  The  patient  was  a  woman  with  a  family  history  replete  with  nervous 
and  mental  defects.  She  feigned  illness  and  tried  to  have  her  arm  amputated. 
Later,  when  discovered,  she  made  believe  that  she  had  a  cardiac  lesion.  Finally, 
she  produced  an  opening  between  the  skin  and  the  stomach.  Through  this  gastric 
fistula  some  interesting  experiments  were  made.  Murchison  collected  the  cases 
in  which  the  stomach  opened  upon  the  abdomen  and  found  that  the  break  seldom, 
if  ever,  occurred  at  the  umbilicus. 

Grawitz  and  Nicolas  both  record  examples  of  an  umbilical  fistula  due  to  a  cut. 
and  Fronmuller  tells  of  a  fistula  due  to  injury  produced  by  a  long  finger-nail. 

Grawitz  showed  a  specimen  coming  from  a  Pole,  who,  in  1849.  was  wounded  in 
the  umbilical  region  with  a  scythe.  A  fecal  fistula  developed  and  persisted  for  the 
remaining  thirty  years  of  his  life.     The  patient  during  his  late  years  grew  thin  and 


FECAL    FISTULA    AT   THE    UMBILICUS.  313 

very  weak,  and  finally  died  of  marasmus.  Several  attempts  were  made  to  close 
the  opening,  but  without  success.  (This  was  before  1878.)  There  was  a  defect 
in  the  abdominal  wall  as  large  as  the  palm  of  the  hand.  The  opening  was  in  the 
small  bowel,  about  1  meter  from  the  stomach. 

Nicolas  refers  to  a  patient  who  had  been  examined  by  Fromantin.*  The 
patient  was  a  soldier  who  had  received  a  cut  in  the  umbilical  region.  The  opening 
was  small,  and  Fromantin  thought  little  of  it,  although  it  occasioned  much  pain. 
On  the  tenth  day  there  was  some  discharge  with  a  fecal  odor.  The  opening  was 
dilated,  and  a  quantity  of  fecal  matter  escaped.  The  fistula  gradually  diminished 
in  size  and  closed. 

Fronmuller  reported  the  case  of  a  man,  forty-eight  years  of  age,  who  had  long 
finger-nails  and  was  of  rather  uncleanly  habits.  After  an  attempt  to  remove  some 
foreign  body  from  the  umbilicus  with  his  finger-nail,  pain  and  swelling  in  the  umbil- 
ical region  came  on  gradually.  When  seen  fourteen  days  later  the  patient  had  a 
yellowish  discharge  from  the  umbilical  depression.  The  umbilicus  was  rather 
tense,  red,  and  half-moon-shaped  on  its  right  side  and  painful  on  pressure.  On  the 
floor  of  the  umbilicus  was  a  large,  red,  fleshy  mass,  and  fluid  was  seen  coming  from 
a  very  fine  opening.  A  sound  introduced  passed  two  inches  into  the  adherent 
bowel.  When  the  patient  lay  on  his  right  side,  the  amount  of  the  discharging  fluid 
increased.  The  patient  had  a  feeling  of  tension  in  the  umbilical  region.  Three 
days  later  silver  nitrate  was  applied,  followed  by  a  second  treatment  after  two  days. 
Four  days  after  the  second  treatment  a  pinkish-red  tumor  developed  in  the  left 
side  of  the  umbilicus.  This  was  accompanied  by  much  pain.  It  broke  two  days 
later  and  a  yellowish-white,  foul-smelling  fluid  escaped.  A  second  fistulous  opening 
now  formed  into  which  a  sound  could  be  carried  three  and  one-half  inches.  From 
time  to  time  other  fistulse  developed  until  six  were  counted. 

When  the  patient  was  seen  four  and  one-half  months  later,  all  these  fistulse  had 
healed,  and  the  man  was  in  good  condition.  Fronmuller  reported  this  case  on 
account  of  its  unusual  character  and  as  an  example  of  a  fistula  due  to  injury  from 
without  and  not  from  within. 


UMBILICAL  FECAL  FISTULA  DUE  TO  BURNS. 

In  the  course  of  a  conversation  with  Dr.  Jesse  W.  Hirst,  of  the  Severance  Hos- 
pital, Seoul,  Korea,  he  told  me  that  in  Korea  the  most  frequent  umbilical  lesion  is  a 
fecal  fistula.  This  is  due  to  the  common  mode  of  treatment  in  cases  of  abdominal 
pain  or  peritonitis. 

The  natives  take  a  piece  of  cotton-wool  and  some  dried  fungus,  roll  the  two  into 
a  small  lump,  and  lay  it  on  the  painful  area.  A  match  is  applied  and  the  roll  is 
allowed  to  burn.  The  result  is  a  sore  about  three-quarters  of  an  inch  in  diameter, 
and  usually  only  skin  deep.  The  desired  result,  namely,  a  running  sore,  is  obtained. 
This  application  is  made  in  some  instances  three  or  four  times.  If  there  is  pain  or 
swelling  in  the  umbilical  region,  the  application  is  made  over  the  umbilicus  and 
frequently  the  surface  of  an  umbilical  hernia  is  burned. 

Dr.  Hirst  observed  about  15  cases  in  which  such  applications  had  been  made  at 
the  umbilicus,  and  in  three  a  fecal  fistula  developed.     The  cause  of  the  fistula  is 

*  Fromantin:  Mem.  d.  l'Acad.  de  chir.,  Paris,  1743,  i,  602. 


314  THE    UMBILICUS   AND    ITS    DISEASES. 

evident.     The  burning  is  sufficient  to  set  up  a  localized  peritonitis,  intestinal  loops 
become  adherent,  and  a  fistula  results. 


LITERATURE  CONSULTED  ON  FECAL  FISTULA  AT  THE  UMBILICUS. 

(See  also  literature  at  end  of  this  chapter.) 

Fronmiiller,  G.:  Kothfistel  im  Nabel.     Memorabilien,  Heilbronn,  1866,  xi,  273. 

Gauderon:   De  la  peritonite  idiopathique  aigue  des  enfants;   de  sa  terminaison  par  suppuration  et 

par  evacuation  du  pus  a  travers  l'ombilic.     These  de  Paris,  1876,  No.  148. 
Grawitz:   Berlin,  klin.  Wochenschr.,  1878,  xv,  9. 
Knecht:    Ausgebreitete  Ulcerationen  im  Dick-  und  Diinndarm,  mit   Perforation  der  vorderen 

Bauchwand.     Arch.  d.  Heilkunde,  1875,  xvi,  539. 
LeCat:  Surun  engorgement  par  congestion  dans  toute  l'etendue  du  peritoine  devenu  suppura- 

toire,  complique  d'adherence  et  d'ulceration  des  intestins  avec  issue  des  matieres  fecales  par 

l'ombilic.     Jour,  de  med.,   1755,    ii,    356.     Also  reported  by  Schrotter:    Arch.  f.  Kinder- 

heilk.,  1902-03,  xxxv,  398. 
Ledderhose:   Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Martin,  M.  E.:    Abces  de  l'ombilic.     Gangrene  et  perforations  intestinales;   peritonite  genera- 

lisee,  mort.     Bull,  de  la  Soc.  anat.  de  Paris,  1872,  xlvii,  148. 
Murchison,  C:  Communication  with  the  Stomach  through  the  Abdominal  Parietes  Produced  by 

Ulceration  from  External  Pressure.     Med.  Chir.  Transactions,  London,  1858,  xli,  11. 
Nicolas,  P. :  Sur  deux  varietes  de  fistules  ombilicales.     These  de  Paris,  1883. 
Trelat:  Fistules  ombilicales.     Jour.  d.  connaiss.  med.  pratiques  et  de  pharm.,  1883, 1,  364. 
Winiwarter,  A. :  Fistula  stercoral,  umbilic.     Jahrb.  f .  Kinderheilk.  und  physische  Erziehung,  N.  F., 

1877,  xi,  193. 


TUBERCULOUS  PERITONITIS  FOLLOWED  BY  A  FECAL  FISTULA  AT  THE 

UMBILICUS. 

As  pointed  out  by  Feulard,  the  opening  at  the  umbilicus  of  a  tuberculous  process 
in  the  peritoneum  is  not  rare.  Fischer  observed  three  cases,  in  two  of  which  there 
was  a  fistulous  opening  between  the  bowel  and  the  umbilical  depression.  The  sub- 
ject has  been  carefully  considered  by  Nicaise,  Ledderhose,  Tillmanns,  Ziehl,  Owen, 
and  others. 

When  a  tuberculous  peritonitis  exists  in  children,  there  seems  to  be  a  definite 
tendency  for  it  to  open  at  the  umbilicus.  Helmreich  (quoted  by  Schrotter)  claimed 
that  of  all  known  cases  of  abdominal  fistula,  three-fourths  developed  at  the  umbili- 
cus. This  seems  to  tally  with  the  experience  of  other  observers.  Heinrich,  in 
1849,  drew  attention  to  several  cases  in  which  the  opening  was  in  the  abdominal  wall 
near  the  umbilicus. 

Ziehl,  in  30  cases  of  abdominal  fistula  following  tuberculous  peritonitis  in  chil- 
dren, found  that  in  18  cases  the  opening  was  at  the  umbilicus. 

In  order  that  we  may  get  a  clear  idea  of  this  class  of  cases  I  have  assembled  a 
group  which  depicts  the  salient  features  of  the  disease.  No  attempt  has  been  made 
to  collect  all  the  cases  recorded  in  the  literature.  We  here  have  records  of  19  cases. 
Sixteen  of  the  patients  were  children.  The  youngest  was  one  year  old.  Eleven 
were  under  ten  years  of  age,  and  five  between  ten  and  sixteen  years  of  age,  these 
figures  being  in  accordance  with  the  claims  of  previous  writers  that  fecal  fistula 
at  the  umbilicus  due  to  tuberculous  peritonitis  is  most  common  in  childhood; 
only  3  of  the  19  patients  were  adults. 

Symptoms. — The  previous  history  in  these  cases,  as  a  rule,  is  colorless,  but  in  a 


FECAL   FISTULA    AT    THE    UMBILICUS.  315 

few  instances  is  of  value.  Crooke's  patient  had  previously  complained  of  pain  in 
the  hip,  and  was  of  a  scrofulous  diathesis.  Clairmont's  gave  a  history  of  a  previous 
pulmonary  affection.  One  of  Ziehl's  patients  had  suffered  from  rickets,  and  another 
from  tuberculosis  of  the  lungs.     Rachford's  patient  also  gave  a  similar  history. 

The  children  usually  first  complain  of  abdominal  distention,  with  or  without 
pain.  This  increases,  the  appetite  gradually  diminishes,  and  emaciation  follows. 
Constipation  develops,  and  may  or  may  not  alternate  with  diarrhea.  As  the  dis- 
ease advances  the  temperature  frequently  rises.  The  pulse  becomes  rapid  and 
small,  the  tongue  is  coated,  and  the  breath  fetid.  Chills  may  accompany  the 
fever,  and,  if  the  lungs  be  involved  in  the  tuberculous  process,  severe  coughing  and 
night-sweats  may  be  present,  and  pleurisy  may  be  detected. 

The  abdominal  enlargement  continues  to  increase,  and  it  may  be  possible  to 
detect  solid  masses  or  an  accumulation  of  abdominal  fluid.  Occasionally  the  diag- 
nosis of  tuberculous  peritonitis  may  be  rendered  more  definite  by  a  rectal  examina- 
tion. In  two  of  Schmitz's  cases  he  was  able,  with  his  finger  in  the  bowel,  to  detect 
small  nodular  masses  in  the  pelvis. 

After  a  varying  length  of  time  the  umbilicus  may  become  altered  in  appearance. 
The  changes  may  occur  in  a  few  months,  but,  as  in  a  case  recorded  by  Nicaise,  a 
year  and  a  half  may  elapse  before  the  slightest  difference  can  be  detected.  The 
picture  varies  considerably.  In  Catteau's  case  a  tumor,  3  cm.  in  diameter,  and 
forming  a  semicircle,  was  noted.  There  was  discoloration  of  the  skin  and  the 
tumor  was  transparent.  In  Baginsky's  case  there  was  a  half-moon-shaped  thicken- 
ing with  the  convexity  directed  downward.  The  skin  was  tense  and  edematous; 
reddening  followed,  and  later  a  fistula  developed,  pus  and  fecal  matter  escaping. 
Ziehl's  patient,  who  was  nearly  four  years  old,  had  a  circumscribed  edema  at  the 
umbilicus,  and  immediately  around  the  depression  were  small,  shot-like  nodules  in 
the  skin.  The  umbilicus  ruptured,  and  a  large  quantity  of  fluid  escaped.  The 
abdomen  collapsed,  and  later  a  round  worm  was  passed  through  the  umbilical  open- 
ing. In  Vallin's  case  there  was  marked  abdominal  reddening  for  a  distance  of  5 
to  6  cm.  around  the  umbilicus.  The  tissue  was  edematous,  and  the  umbilical  folds 
were  distended.  This  condition  persisted  for  two  months.  The  redness  then  dis- 
appeared, and  a  nodule  the  size  of  a  walnut  and  containing  gas  and  fluid  appeared 
at  the  umbilicus.  In  Crooke's  case  there  was  a  marked  prominence  at  the  umbilicus, 
followed  by  the  escape  of  pus  and  feces.  In  Rintel's  case  the  umbilical  ring  opened 
and  pus  escaped  with  great  force.  In  Schmitz's  eleven-year-old  patient  the  umbil- 
ical walls  were  exceedingly  thin,  and  gas  and  fluid  could  be  seen  through  the  skin. 
Bertherand's  patient  had  a  conic  umbilicus  and  a  prominence  the  size  of  an  almond. 
The  overlying  skin  was  mottled.  The  tumor  contained  fluid  with  gas,  and  could 
be  reduced. 

From  the  foregoing  it  will  be  noted  that  the  inflammatory  changes  at  the  umbil- 
icus are  of  slow  development,  and  that  the  abdominal  fluid  reaches  the  surface  by 
two  methods — either  by  gradual  disintegration  of  the  abdominal  wall  or  by  dis- 
tention of  the  umbilical  opening,  which  allows  the  fluid  to  escape  into  the  hernial 
protrusion.  In  addition  to  the  opening  at  the  umbilicus  a  secondary  one  may 
develop  in  the  vicinity. 

The  tuberculous  process  gradually  advances,  and,  if  the  lungs  have  not  already 
been  involved,  they  are  apt  now  to  be  implicated.  The  child  grows  weaker  and 
weaker,  and  usually  dies  a  few  weeks  after  the  umbilicus  has  opened. 


316  THE    UMBILICUS   AND    ITS    DISEASES. 

Autopsy  Findings.- —  At  the  umbilicus  the  fistula  found  varies  from 
one  to  several  millimeters  in  diameter.  The  surrounding  skin  may  or  may  not 
show  marked  irritation,  depending  upon  the  situation  of  the  opening  into  the  bowel 
and  on  the  irritating  character  of  the  discharge.  In  some  cases  the  skin,  fascia, 
muscle,  and  peritoneum  are  so  intimately  blended  as  a  result  of  the  inflammation 
that  it  is  almost  impossible  to  separate  them. 

When  the  abdomen  is  opened,  a  loop  of  small  or  large  bowel  is  often  found  firmly 
fixed  to  the  opening  at  the  umbilicus,  and  it  is  from  this  that  the  feces  escape. 
Sometimes  two  or  more  loops  are  adherent  to  the  umbilicus.  In  those  cases  in 
which  the  umbilicus  was  distended  and  gas  and  feces  could  be  distinctly  made 
out,  there  was  usually  a  cavity  of  considerable  size  lying  immediately  beneath  the 
umbilicus.  At  one  or  more  points  the  lumen  of  the  small  bowel  or  of  the  large 
bowel,  or  the  lumina  of  both,  communicated  with  the  cavity.  The  walls  of  the  cavity 
were  composed  of  intestinal  loops  alone,  or  of  intestinal  loops,  one  or  more  of  the 
abdominal  organs,  the  omentum,  and  the  abdominal  wall.  When  the  intestinal 
perforation  occurs,  the  surrounding  tissue  naturally  tends  to  wall  it  off  at  once  if 
adhesions  have  not  already  formed.  The  cavity  may  be  small,  or  occupy  fully 
half  the  abdomen.  Its  inner  surface  resembles  granulation  tissue,  and  it  contains 
pus  and  fecal  matter.  Definite  tuberculous  masses  have  in  some  cases  been  noted 
in  the  wall  of  the  sac.  The  intestinal  loops  throughout  the  abdomen  are  usually 
adherent,  and  between  them  are  tubercles,  accumulations  of  serous  or  flocculent 
material,  or  pus,  according  to  the  stage  of  the  disease  and  the  presence  or  absence 
of  a  mixed  infection. 

In  those  cases  in  which  sudden  death  has  occurred,  as  in  those  of  Bertherand 
and  Vallin,  the  walls  of  the  cavity  have  given  way,  allowing  fecal  matter  to  escape 
into  the  general  abdominal  cavity.  With  the  patient  in  an  already  weakened  con- 
dition, the  shock  has  been  sufficient  to  occasion  sudden  death. 

An  associated  pulmonary  tuberculosis  is  often  noted  at  autopsy. 

Differential  Diagnosis.  —  In  making  the  diagnosis  it  is  necessary 
to  exclude  the  possibility  of  an  umbilical  concretion,  carcinoma,  other  forms  of 
peritonitis  opening  at  the  umbilicus,  and  other  umbilical  fistulse.  Umbilical  con- 
cretions occur  during  the  active  working  period  of  life;  tuberculous  fistulse  pre- 
ponderate in  childhood.  Carcinoma  is  also  a  disease  of  middle  life  or  of  old  age, 
and  is  thus  readily  excluded.  Any  form  of  peritonitis  followed  by  an  escape  of  pus, 
and  possibly  feces,  at  the  umbilicus  may  at  first  be  confused  with  tuberculous  peri- 
tonitis. The  onset  of  a  purulent  peritonitis  is,  however,  usually  very  acute;  the 
disease  runs  a  rapid  course,  and  the  child  either  speedily  dies  or  rapidly  recovers. 
Umbilical  fistulse  due  to  round  worms  escaping  through  the  bowel  and  passing  out 
through  the  umbilicus  may  for  a  time  occasion  some  confusion,  but  with  the  escape 
of  the  worms  the  fistula  may  close,  while  in  cases  of  tuberculous  peritonitis  the  con- 
dition goes  from  bad  to  worse. 

Treatment.  —  With  the  early  recognition  of  tuberculous  peritonitis  and 
its  appropriate  treatment — laparotomy — cases  of  umbilical  fistula  will  naturally 
diminish  in  number.  As  emphasized  by  Tillmanns,  poultices  are  to  be  strenuously 
avoided.  As  has  been  said,  the  umbilicus  may  be  reddened  for  months  without 
the  formation  of  a  fistula,  but  once  feces  commence  to  escape  by  this  channel,  the 
fistula  remains  open  until  death. 


FECAL    FISTULA    AT    THE    UMBILICUS.  317 

CASES  OF  TUBERCULOUS  PERITONITIS  WITH  A  FECAL  FISTULA 
DEVELOPING  AT  THE  UMBILICUS. 

Umbilical  Fecal  Fistula  Due  to  Tuberculous  Peri- 
tonitis.* —  A  boy,  one  year  and  three  months  old,  was  admitted  to  the  hos- 
pital on  December  23,  1879,  for  an  otitis  purulenta.  He  was  fairly  well  nourished 
and  showed  no  signs  of  rickets.  The  abdomen  was  hard  and  distended.  At  the 
umbilicus  was  a  half-moon-shaped  thickening,  with  the  convexity  directed  down- 
ward; the  overlying  skin  was  tense  and  edematous.  The  condition  remained  the 
same  until  February  9,  1880.  At  this  time  examination  of  the  thorax  was  negative. 
Around  the  umbilicus,  especially  in  the  lower  portion,  there  were  edema  and  redden- 
ing. There  was  definite  fluctuation.  The  abdomen  itself  was  hard  and  distended, 
but  no  palpable  tumor  could  be  detected.  On  February  12th  an  opening,  the  size 
of  a  bean,  was  detected  at  the  umbilicus,  and  from  this  a  considerable  quantity  of 
fecal  material  and  purulent  fluid  escaped.  When  the  child  was  raised  up,  these 
fecal  masses  escaped  readily.     He  died  on  February  13th. 

At  autopsy  the  body  was  markedly  emaciated  and  anemic.  The  lower  lobe  of 
the  right  lung  was  reddish  gray.  The  costal  pleurae  and  the  diaphragm  and  peri- 
cardium were  covered  with  grayish  miliary  tubercles.  The  diaphragm,  liver,  and 
spleen  were  completely  adherent  to  the  abdominal  wall.  The  purulent  cavity 
beneath  the  umbilicus  was  walled  off  by  these  and  the  omentum,  and  the  cavity 
extended  into  the  pelvis.  The  pelvis  was  filled  with  feces  and  purulent  fluid,  and 
the  intestinal  convolutions  of  the  lower  abdomen  were  covered  with  a  greenish, 
necrotic  deposit,  and  at  several  points  were  perforated.  Through  one  perforation 
the  little  finger  could  be  passed  into  the  small  bowel.  At  this  point  the  vermiform 
appendix  had  ulcerated.  On  the  left  side  of  the  transverse  colon  were  numerous 
ulcers,  some  of  which  had  extended  only  through  the  mucosa.  At  other  points 
they  had  perforated  the  entire  thickness  of  the  bowel,  opening  into  a  cavity  situated 
at  the  vertebral  column.  The  mesenteric  glands  were  markedly  swollen  and  case- 
ous.    In  the  spleen  were  numerous  nodules. 

Intestinal  and  Peritoneal  Tuberculosis  with  Per- 
foration and  the  Formation  of  a  Fecal  Reservoir  Open- 
ing at  the  Umbilicus. f  —  A  soldier  came  under  observation  on  September 
21,  1851,  on  account  of  obstinate  diarrhea.  On  February  16,  1852,  he  had  severe 
abdominal  pain  and  dysuria.  On  May  12th  of  the  same  year  for  the  third  time  he 
presented  the  picture  of  marked  disturbances  of  nutrition.  His  pulse  was  rapid 
and  small,  and  there  was  marked  emaciation.  Diarrhea  was  present,  and  he  had  a 
dry  cough  and  night-sweats.  The  abdomen  was  very  painful  and  distended. 
From  the  pubes  to  a  point  above  the  umbilicus  was  a  doughy,  immovable  tumor  of 
nodular  character.  All  indications  pointed  to  a  chronic  mesenteric  inflammation. 
On  June  10,  1852,  there  developed  beneath  the  umbilicus  a  conic  prominence  the 
size  of  a  large  almond.  The  skin  over  it  was  mottled.  The  tumor  was  reducible 
and  filled  with  fluid  and  gas.  A  few  days  later  the  prominence  was  incised,  and 
there  escaped  blood,  pus,  foul-smelling  gas,  and  a  little  later  fecal  matter.     Fecal 

*  Baginsky:  Zur  Demonstration  eines  Praparates.  Verhandl.  d.  Berl.  med.  Gesellschaft, 
Jahrg.  1879-80,  xi,  90. 

t  Bertherand,  A. :  Observation  d'entero-peritonite  tuberculeuse  avec  perforations  intestinales, 
formation  d'un  reservoir  stercoral  sous  la  paroi  abdominale;  fistule  ombilicale.  Gaz.  med.  de 
Strasbourg,  Novembre,  1852,  douzieme  annee,  572. 


318  THE    UMBILICUS    AND    ITS    DISEASES. 

matter  also  passed  through  the  rectum.  During  the  night  of  June  18th  the  patient 
raised  himself  suddenly  and  died  with  a  loud  cry. 

At  autopsy  it  was  found  that  there  was  a  deep  pus-cavity  behind  the  umbilicus. 
This  was  filled  with  old  pus  and  tuberculous  masses.  The  anterior  wall  of  the  cav- 
ity appeared  to  be  formed  of  the  posterior  surface  of  the  transversalis  muscle  and 
remains  of  the  peritoneum.  The  posterior  wall  was  bounded  by  two  thick  layers 
of  large  omentum,  which  laterally  was  adherent  to  the  peritoneum,  thus  fastening 
the  intestinal  loops  together.  The  inner  irregular  cavity  communicated  behind  and 
above  with  the  transverse  colon  through  two  holes,  15  and  18  mm.  in  diameter. 
At  the  end  of  the  ileum  were  three  openings  with  sharp  margins,  probably  resulting 
from  freshly  broken-down  tubercles.  From  these  had  escaped  the  fresh  fecal 
masses  which  were  found  in  the  abdomen,  and  thus  the  sudden  death  is  explained. 
There  was  a  direct  connection  between  the  umbilical  opening  and  the  pus-sac. 

In  this  case  there  was  also  a  pulmonary  tuberculosis. 

Tuberculous  Peritonitis  with  Dilatation  of  the 
Umbilical  Ring.*  —  A  man,  forty-one  years  of  age,  had  a  peritoneal 
tuberculosis.  At  the  umbilicus  was  a  transparent  tumor,  3  cm.  in  diameter,  form- 
ing three-quarters  of  a  circle.  There  was  no  discoloration  of  the  skin.  The  tumor 
was  easily  reducible,  and  the  finger  could  be  carried  into  the  abdomen.  [This  was 
evidently  a  small  umbilical  hernia  containing  ascitic  fluid.  It  is  recorded  here  to 
show  the  early  umbilical  changes  before  a  fecal  fistula  has  developed. — T.  S.  C] 

Fecal  Fistula  Probably  Due  to  Tuberculous  Peri- 
tonitis, f  —  A  boy,  fifteen  years  old,  in  1897  had  inflammation  of  the  lungs 
and  also  of  the  abdomen.  In  June  of  the  same  year  he  complained  of  pain  in  the 
abdomen  and  noticed  a  swelling.  Owing  to  increased  pain  and  fever  the  patient 
went  to  bed  in  September.  In  October  pus  was  found  escaping  from  the  umbilical 
region.  After  this  the  pain  eased  up,  but  a  fistula  persisted,  and  there  was  a  vary- 
ing degree  of  pain.  In  April,  1898,  the  pain  became  severe  in  the  right  side.  In 
June,  1898,  the  boy  appeared  to  be  well  developed  and  showed  no  definite  changes 
in  the  chest,  but  the  abdomen  in  the  umbilical  region  was  still  distended.  At  the 
umbilicus  the  fistula  still  secreted  a  little,  and  occasionally  a  small  amount  of  fecal 
matter  escaped. 

Operation. — Under  ether  below  the  fistula  a  resistant  area,  about  the  size  of  a 
five-mark  piece,  could  be  felt.  Pressure  on  this  caused  a  discharge  of  pus.  The 
fistulous  tract  was  dissected  out,  and  during  the  manipulations  a  second  loop  of  bowel 
was  opened  up,  but  was  closed  immediately.  The  opening  in  the  bowel  was  about  the 
size  of  a  five-pfennig  piece,  and  the  walls  of  the  bowel  at  this  point  were  infiltrated. 
In  addition,  there  were  numerous  loops  of  small  bowel  adherent  to  the  anterior 
abdominal  wall  in  the  region  of  the  umbilicus.  The  portion  of  the  bowel  forming 
the  fistula  was  resected.  Extraperitoneally  and  to  the  left  of  the  umbilicus  was 
a  caseous  focus,  4  cm.  long  and  2  cm.  broad.  This  was  drained.  At  operation  the 
ends  of  the  bowel  were  held  in  place  by  a  Murphy  button,  which  came  away  on  the 
eleventh  day. 

[This  case  seems  to  be  one  of  tuberculous  peritonitis. — Ti  S.  C] 

*  Catteau,  J.  F. :  De  l'ombilic  et  de  ses  modifications  dans  les  cas  de  distension  de  l'abdomen. 
These  de  Paris,  1876,  obs.  10. 

fClairmont,  Paul:  Casuistischer  Beitrag  zur  Radicaloperation  der  Kothfistel  und  des  Anus 
praeternaturalis.  Klinik,  Prof.  v.  Eiselsberg,  Konigsberg.  Langenbeck's  Arch.  f.  klin.  Chir., 
1901,  lxiii,  691. 


FECAL    FISTULA    AT    THE    UMBILICUS.  319 

Tuberculous  Peritonitis  Followed  by  Perforation 
at  the  Umbilicus.*  —  An  eleven-year-old  boy  with  a  definite  scrofulous 
diathesis  had  suffered  for  eighteen  months  from  vomiting  and  from  pain  in  the  hip. 
At  the  umbilicus  there  was  also  pain.  The  child  lay  with  his  thighs  drawn  up. 
Some  time  later  marked  diarrhea  was  noted  and  severe  pain  in  the  umbilical  region. 
This,  in  the  course  of  six  weeks,  became  markedly  prominent  as  a  result  of  abscess 
formation.  About  three  weeks  later  there  was  a  spontaneous  opening  at  the  umbil- 
icus, with  the  escape  of  purulent  fecal  masses.  A  month  later  a  similar  tumor 
developed,  two  and  a  half  inches  below  the  umbilicus.  This  broke  at  three  points. 
From  the  upper  opening  fecal  matter  escaped,  while  the  lower  discharged  serous 
material.  The  bowels  were  regular,  and  the  appetite  was  good.  In  the  course  of 
six  weeks  the  abdomen  became  flattened  and  the  pulse  small;  the  appetite  was 
poor.  There  was  marked  pain  at  the  umbilicus.  Three  months  later  the  child 
died. 

At  autopsy  the  omentum  was  found  adherent  to  the  abdominal  wall.  The  under- 
lying intestines  had  grown  fast  to  one  another.  Tubercles  were  found  in  the  left 
iliac  region,  under  the  descending  colon,  and  also  beneath  the  peritoneum  of  the 
anterior  stomach-wall.  In  the  lower  part  of  the  ileum,  about  six  inches  from  the 
cecum,  were  the  remains  of  a  large  tubercle  which  had  broken  down.  Here  it  was 
found  that  the  intestine  had  become  adherent  to  the  umbilicus  and  communicated 
with  the  opening  from  the  bowel.  In  the  peritoneum  itself  were  several  minute 
tubercles.  The  spleen  was  enlarged,  and  the  mesenteric  lymph-glands  were  hard 
and  gritty. 

Tuberculous  Fistula  at  the  Umbilicus,  f  —  This  case  came 
under  Habershon's  observation.  The  patient  was  a  small  girl,  six  years  old,  who 
had  had  chronic  peritonitis  for  a  year.  Six  months  before  her  death  a  tumor 
appeared  at  the  umbilicus.  This  opened,  and  a  fistula  resulted  from  which  pus 
mixed  with  fecal  matter  escaped.  At  autopsy  pulmonary  and  peritoneal  tuber- 
culosis was  found.  The  intestines  were  adherent;  several  loops  had  perforated, 
and  a  fecal  fistula  had  formed,  with  an  exit  at  the  umbilicus. 

Probable  Tuberculous  Fistula  at  the  Umbilicus.!  — 
The  patient  was  a  small  Italian  child.  There  was  a  fecal  discharge  from  the  umbili- 
cus, through  several  openings.     The  child  died  of  tuberculous  peritonitis. 

Artificial  Anus  Established  Spontaneously  Through 
the  Umbilicus.§  —  A  boy,  nine  years  old,  had  been  under  treatment  for 
six  months  on  account  of  a  peritoneal  and  pulmonary  tuberculosis.  In  February, 
1891,  the  umbilical  region  was  found  to  be  sensitive,  red,  and  more  prominent  than 
the  already  distended  abdomen.  On  February  13th  the  boy's  father  came  and 
said  that  the  abdomen  had  flattened  out  and  that  the  stools  were  coming  from  the 
umbilicus.  Light  pressure  was  made  on  the  abdomen,  and  gas  and  fecal  matter 
escaped  through  an  opening,  and  the  boy  felt  as  well  as  usual.  Six  hours  later  his 
temperature  was  99°  F.,  and  fecal  matter  and  gas  continued  to  escape  from  the 

*  Crooke,  E.  G.:  On  a  Case  of  Tubercular  Peritonitis  Followed  by  Perforation  of  the  Ab- 
dominal Parietes.     The  Lancet,  1849,  ii,  668. 

f  Nicaise:    Ombilic.     Dictionnaire  encyclopedique  des  sc.  med.;  Paris,  1881,  2.ser.,  xv,  140. 

|  Park,  Roswell:  Clinical  Lecture  on  Congenital  Fistula?  and  Sinuses  at  the  Umbilicus. 
Med.  Fortnightly,  1896,  ix,  9. 

§  Rachford:  Arch,  of  Pediatrics,  1891,  viii,  680. 


320  THE    UMBILICUS    AND    ITS    DISEASES. 

umbilicus.  From  the  rectum  no  stools  passed.  By  means  of  a  bandage  the  feces 
could  be  entirely  controlled.  After  the  perforation  at  the  umbilicus  the  boy  felt 
better  and  developed  an  appetite,  and  his  night-sweats  disappeared.  On  March 
10th  he  complained  of  sudden  pain  in  the  abdomen,  collapsed,  and  died  the  next  day. 

Autopsy. — Only  the  abdomen  could  be  examined.  The  intestines  had  been 
transformed  into  a  large,  hard  tumor,  as  a  result  of  tuberculous  masses.  In  the  trans- 
verse colon  was  a  round  perforation  the  size  of  a  ten-cent  piece,  with  thick  margins. 
On  the  outer  side  of  the  intestine,  around  the  opening,  was  a  rough,  red  circle  about 
an  inch  and  a  half  in  diameter,  where  the  intestine  had  been  adherent  to  the  abdomi- 
nal wall  around  the  umbilicus.  The  umbilical  opening  passed  into  a  cavity  which 
was  filled  with  fecal  matter.  From  this,  one  opening  was  found  entering  the  ileum 
and  another  the  ascending  loop  of  the  transverse  colon.  Scattered  throughout  the 
peritoneum  were  tubercles.  Some  showed  definite  inflammation,  others  had  gone 
on  to  suppuration. 

The  bowel  had  evidently  torn  partly  loose  from  the  abdominal  wall,  allowing  the 
fecal  matter  to  escape  into  the  general  cavity.  This  explains  the  faintness  with 
the  pain  and  collapse  that  followed. 

A  Case  of  Tuberculosis  of  the  Intestine  with  Per- 
foration of  the  Duodenum  and  Cecum  into  the  Peri- 
toneal Cavity.  Fecal  Fistula  at  the  Umbilicus.*  —  A  three- 
and-one-half -year-old  girl  complained  of  pain  in  the  abdomen  and  of  loss  of  appetite. 
Over  the  surface  of  the  distended  abdomen  bluish,  dilated  veins  were  noted.  There 
was  free  fluid  in  the  abdomen.  In  the  inguinal  region  on  both  sides  the  glands 
were  enlarged.  After  two  months  pain  and  severe  fever  developed,  and  two  days 
later  the  umbilical  ring  opened  and  there  was  an  escape,  with  great  force,  of  a 
purulent  fluid  having  a  foul  odor  and  mixed  with  yellow  fecal  matter.  Fecal  matter 
continued  to  escape  from  this  opening  and  also  from  the  rectum  until  the  child's 
death.  Emaciation  increased;  the  urinary  secretion  stopped  almost  completely. 
The  child  died  a  month  after  the  umbilical  opening  appeared. 

At  autopsy  the  abdomen  was  markedly  distended,  especially  in  the  vicinity  of 
the  umbilicus,  where  there  was  an  opening  the  size  of  a  pin-head.  On  pressure, 
clear,  yellow,  thin  fecal  material  escaped  drop  by  drop. 

A  fine  sound  could  be  passed  directly  downward  to  the  vertebral  column. 
On  palpation  very  hard  nodular  masses  could  be  felt  around  the  umbilicus.  When 
the  abdomen  was  opened,  the  anterior  wall  above  the  umbilicus  was  found  adherent 
to  the  omentum.  On  the  opposite  side  the  wall  was  united  with  the  transverse 
colon  by  thick,  firm  adhesions.  Here  had  formed  the  cavity  that  communicated 
with  the  umbilicus  through  the  canal  mentioned,  and  through  an  opening  into  the 
duodenum  the  size  of  a  Groschen  (five-cent  piece) .  Just  below  the  opening  of  the 
bile-duct  there  was  another  perforation  into  the  colon.  The  cavity  produced  was 
filled  with  fecal  masses,  and  the  small  intestine  was  involved  in  the  exudate.  In 
the  cecum  was  an  ulcer  which  extended  almost  to  the  peritoneal  surface,  and 
directly  at  the  ileocecal  valve  was  another  perforation.  The  vermiform  appendix 
had  also  been  destroyed.  The  upper  part  of  the  cecum  and  the  lower  part  of  the 
ileum  were  firmly  glued  to  the  wall  of  the  cavity.  There  were  numerous  ulcers 
throughout  the  intestines.     Both  lungs  were  normal. 

*  Rintel:    Ein  Fall  von  Darmtuberculose  mit  Perforation  des  Duodenum  und  Caecum  in's 
Cavum  peritonei.     Berlin,  klin.  Wochenschr.,  1867,  iv,  332. 


FECAL   FISTULA    AT   THE    UMBILICUS.  321 

Tuberculous  Fecal  Fistula  at  the  Umbilicus.*  —  A 
girl,  fourteen  years  old,  at  first  complained  of  severe  abdominal  pain  in  the  hypo- 
gastric, hypochondriac,  and  umbilical  regions.  Several  months  later  she  returned 
to  the  hospital  with  a  round  opening  at  the  umbilicus.  Its  margins  were  slightly 
excoriated,  and  fecal  matter  was  escaping.  Her  constitution  had  been  weakened, 
and  general  tuberculosis  had  existed  for  six  months. 

At  autopsy  pelvic  peritonitis  was  found.  The  intestinal  loops  were  adherent  to 
each  other,  and  between  them  were  purulent  foci.  A  loop  of  small  bowel  had 
opened  at  the  umbilicus. 

Cases  of  Fecal  Fistula  at  the  Umbilicus  Due  to  Tu- 
berculous Peritonitis. f  —  Case  1.  —  A  girl,  eleven  years  of  age, 
had  been  ill  for  three  or  four  months.  She  had  had  abdominal  distention  with 
diarrhea  and  was  emaciated.  On  admission  the  abdomen  was  much  distended. 
At  the  umbilicus  there  was  sensitiveness  on  pressure.  The  umbilicus  was  covered 
over  with  very  thin  skin,  and  immediately  beneath  were  gas  and  fluid.  The  patient's 
temperature  was  subnormal. 

An  incision  was  made  opening  up  a  fecal  abscess,  at  the  bottom  of  which  was  an 
intestinal  fistula.     The  child  died  on  the  tenth  day. 

At  autopsy  the  organs  of  the  lower  abdomen  were  found  grown  together  and 
forming  a  tangled  mass.  Between  them  were  numerous  caseous  foci.  Opening 
into  the  posterior  wall  of  the  umbilical  abscess  were  several  small  holes  which  com- 
municated with  the  intestine.     There  was  a  total  adhesive  pericarditis. 

Case  2  .  —  A  boy,  six  years  old,  for  two  and  one-half  months  had  had  fever, 
pain  in  the  abdomen,  and  vomiting.  For  one  month  he  had  had  obstinate  consti- 
pation. The  abdomen  had  increased  in  size,  and  emaciation  had  become  marked. 
For  one  week  there  had  been  a  reddening  at  the  umbilicus.  The  mesogastrium  and 
hypogastrium  were  filled  with  nodular  tumors.  On  rectal  examination  minute  hard 
nodules  could  be  felt.     The  child  had  intermittent  fever. 

Operation. — Beneath  the  umbilicus  was  a  large,  foul-smelling  accumulation  of 
pus.  The  abdomen  was  studded  with  tubercles.  The  omentum  was  markedly 
adherent.  When  the  bandages  were  changed,  an  abundant  quantity  of  fecal 
matter  came  out  of  the  cavity.  The  fever  continued,  and  the  patient  died  three 
weeks  later. 

Autopsy. — Folds  of  the  peritoneum  were  adherent  to  one  another  at  many  points. 
Between  them  were  isolated  and  confluent  tuberculous  nodules.  Similar  nodules 
were  also  found  in  the  omentum.  In  the  ascending  colon  was  a  perforation  ad- 
mitting the  tip  of  the  finger.  About  20  cm.  above  this  point  was  a  small  group  of 
miliary  tubercles  in  the  mucosa.  In  the  lower  portion  of  the  large  bowel  were 
several  flat  ulcers  with  thickened  margins.  The  remaining  portion  of  the  intestinal 
tract  was  normal.  In  the  pelvis,  between  intestinal  loops,  was  an  isolated  abscess, 
and  the  liver  and  spleen  were  covered  with  adhesions.  There  was  a  pleurisy  on  the 
left  side.  The  pleurae  of  both  lungs  were  studded  with  tubercles.  The  bronchial 
glands  were  swollen. 

Case    3  .  —  A  girl,  nine  years  old,  from  September,   1892,  had  had  acute 

*  Rombeau:  Anus  contre  nature,  suite  de  peritonite.  Bull,  de  la  Soc.  anat.  de  Paris,  1851, 
xxvi,  366. 

f  Schmitz,  A.:  Ueber  Bauchfelltuberculose  der  Kinder.  Jahrb.  f.  Kinderheilk.,  1897,  xliv, 
316. 

22 


322  THE    UMBILICUS    AND    ITS    DISEASES. 

abdominal  pain,  fever,  and  obstipation,  and  there  had  been  a  gradual  increase  in 
the  size  of  the  abdomen.  In  May,  1893,  a  swelling  at  the  umbilicus  associated  with 
redness  was  noted.  The  mass  was  of  the  size  and  form  of  a  fist.  It  broke,  and  feces 
escaped.  In  July  the  patient  was  markedly  anemic  and  the  abdomen  was  enlarged 
and  painful.  At  the  lower  margin  of  the  umbilicus  was  a  fecal  fistula,  which  was 
discharging  the  contents  of  the  small  bowel.  The  inguinal  glands  were  swollen. 
By  the  rectum  several  flat  nodules  could  be  felt. 

Operation. — The  omentum  was  adherent  to  the  small  intestine  and  to  the  parie- 
tal peritoneum.  Numerous  hard  nodules,  some  as  large  as  a  pea,  were  found. 
The  umbilical  fistula  led  to  a  fecal  opening  the  size  of  a  walnut.  This  communi- 
cated with  a  loop  of  small  bowel  by  an  opening,  3  cm.  in  diameter.  The  patient 
died  five  days  later. 

At  autopsy  general  adhesions  of  the  intestine  with  the  parietal  peritoneum,  the 
omentum,  and  liver  were  found.  There  were  also  numerous  peritoneal  tubercles. 
In  the  capsules  of  the  liver  and  spleen  were  tubercles.  The  uterus  was  increased 
in  size;  its  cavity  was  dilated  and  filled  with  cheesy  pus,  and  the  mucosa  was  cov- 
ered with  a  cheesy  membrane.  In  the  ileum  was  a  perforated  ulcer,  1.5  cm.  in 
diameter.  The  fistula  in  the  ileum  had  been  closed  tightly  at  operation.  The 
mesenteric  glands  had  undergone  caseation.  The  mucosa  of  the  intestine  was 
swollen,  but  free  from  tuberculous  ulcers. 

Tuberculosis  of  the  Umbilical  Region.*  —  A  boy,  sixteen 
years  of  age,  was  said  to  have  had  a  fall  in  the  latter  half  of  1895.  Before  admission 
the  abdomen  had  become  much  distended.  Immediately  before  the  operation  it 
was  noted  that,  for  his  age,  he  was  larger  than  usual  and  very  thin.  The  abdomen 
was  markedly  and  uniformly  distended;  the  umbilicus  was  pushed  forward  some- 
what like  a  bladder.  The  skin  was  of  the  thinness  of  paper.  Surrounding  the 
umbilicus  the  tissue  was  red  and  painful  on  pressure,  and  over  the  entire  abdomen 
there  were  dulness  and  a  sensation  of  fluctuation. 

On  April  17,  1896,  an  incision  was  made  extending  from  the  ensiform  cartilage 
through  the  umbilicus  to  three  fingerbreadths  above  the  symphysis.  There 
escaped  between  10  and  12  liters  of  very  cloudy,  odorless  fluid,  which  contained 
numerous  white,  grayish  flocculi  and  a  membranous  network.  The  greater  amount 
of  fluid  was  found  in  the  anterior  portion  of  the  sac.  On  pressure  and  when  the 
patient  was  turned  on  his  side,  however,  an  abundance  of  fluid  escaped  from  the 
posterior  portion.  Schrotter  thought  he  was  dealing  with  tuberculosis,  but  no 
tubercle  bacilli  were  found  and  no  tissue  that  histologically  gave  that  picture. 
[In  this  case  no  fistula  existed. — T.  S.  C] 

Umbilical  Fecal  Fistula  Due  to  Tuberculous  Peri- 
tonitis. —  Schrotter  f  (p.  415)  reports  an  observation  by  Jung. 

The  patient  was  a  scrofulous,  emaciated  child,  three  years  and  nine  months  old. 
The  abdomen  was  distended,  especially  around  the  umbilicus,  where,  after  the 
application  of  poultices,  an  abscess  formed.  This  broke,  and  feces,  pus,  and  blood 
escaped.  The  child  died,  and  at  autopsy  the  intestines  were  found  adherent  to 
one  another  and  to  the  peritoneum.     The  intestine  at  one  point  had  perforated. 

*  Schrotter:   Zur  Kenntnis  der  Tuberculose  der  Nabelgegend.     Arch.  f.  Kinderheilk.,  1902- 
03,  xxxv,  398. 

f  Schrotter:  Op.  fit.,  p.  415.     Rhein.  Generalberioht.  Ref.  Canstatt's  Jahresbericht,  1842,  ii. 


FECAL    FISTUL.E    AT    THE    UMBILICUS.  323 

Peritoneal  Tuberculosis  with  Fecal  Fistula  at  the 
Umbilicus.*  —  An  eight-year-old  girl  had  swelling  of  the  abdomen.  Her 
tongue  was  coated,  the  breath  was  fetid,  and  she  had  a  severe  cough.  Her  skin 
was  of  a  dark  brownish  color.  She  had  diarrhea,  and  there  was  edema  in  the  lower 
part  of  the  abdomen  and  in  the  legs.  Indefinite  fluctuation  could  be  made  out  in 
the  lower  abdomen.  Later  on  the  lower  abdomen  presented  a  conic  form,  the  um- 
bilicus forming  the  point  of  the  cone.  It  opened,  and  from  it  escaped  brownish 
fecal  material  of  a  very  foul  odor.  No  feces  passed  through  the  rectum  from  that 
time.     Three  weeks  later  the  patient  died. 

At  autopsy  the  intestines  were  found  adherent  to  one  another  and  to  the 
abdominal  wall,  except  in  the  lower  right  side,  where,  between  the  anterior  wall 
and  the  intestine,  fecal  masses  were  found.  The  whole  of  the  peritoneum,  both 
that  covering  the  abdominal  wall  and  that  of  the  viscera,  was  riddled  with  tubercles^ 
some  of  which  had  become  caseous.  The  mesenteric  glands  were  enlarged  and 
tuberculous. 

In  this  case  there  was  tuberculous  disease  of  the  mesenteric  glands  with  a  healthy 
intestinal  mucosa. 

Umbilical  Inflammation  Following  Tubercular  Peri- 
tonitis, f  —  A  soldier,  twenty-two  years  of  age,  who  is  said  to  have  been  pre- 
viously healthy  and  strong,  a  month  before  admission  noticed  a  swelling  of  the  abdo- 
men. His  appetite  diminished,  he  had  obstipation  alternating  with  diarrhea,  but 
never  vomited  and  had  no  cough.  On  December  8,  1867,  there  was  abdominal  dis- 
tention. Palpation,  however,  was  not  painful.  In  the  hypogastric  region  was  a 
definite  fluctuation.  On  December  20th  he  noticed  a  marked  reddening  around  the 
umbilicus.  The  skin  in  the  umbilical  region,  for  a  distance  of  5  or  6  cm.,  was  edema- 
tous, and  the  umbilical  folds  were  distended.  There  was  no  pain,  and  the  over- 
lying skin  was  not  sensitive.  The  reddening  and  edema  remained  unchanged  for 
two  months.  At  the  end  of  January  the  exudate  in  the  abdomen  had  disappeared, 
but  the  distention  had  increased  and  the  patient  was  cachectic.  He  had  fever,  a 
dry,  hot  skin,  and  marked  night-sweats.  The  umbilicus  remained  the  same.  Com- 
mencing February  16th  a  pleurisy  was  noticed,  and  the  weakened  condition  of  the 
patient  increased.  There  was  diarrhea.  The  skin  at  the  umbilicus  was  not  so 
red,  but  for  fourteen  days  had  taken  on  a  yellowish  color,  and  at  the  umbilicus  there 
was  a  small,  irreducible  tumor  the  size  of  a  walnut,  which  contained  gas  and  fluid. 
On  February  27,  1868,  at  4  o'clock  in  the  morning,  the  patient  felt  something 
tear.  The  umbilicus  broke,  and  there  was  an  abundant  discharge  of  cloudy  fluid 
with  a  feculent  appearance.     He  died  an  hour  later. 

At  autopsy  marked  emaciation  was  noted.  The  abdomen  was  sunken.  The 
umbilical  scar  on  the  left  side  was  irregular  and  torn,  and  there  escaped  on  light 
pressure  a  yellow,  diarrhea-like  fluid.  The  anterior  abdominal  wall  was  difficult 
to  loosen  on  account  of  extensive  adhesions  to  the  intestine  and  omentum.  The 
muscle,  aponeurosis,  and  skin  were  thickened,  and  had  grown  fast  to  one  another, 
so  that  their  separation  was  possible  only  by  careful  dissection  with  the  knife. 
The  liver,  stomach,  and  transverse  colon  were  firmly  united  to  the  abdominal  wall. 

*  Scott,  John:    Perforation  of  the  Intestine  with  External  Opening.     Edinburgh  Med.  and 
Surg.  Jour.,  1835,  xliii,  97. 

|  Tallin,  E.:    De  l'inflammation  periombilicale  dans  la  tuberculisation  du  peritoine.     Arch, 
gen.  de  rued.,  1S69,  xiii,  558. 


324  THE    UMBILICUS   AND    ITS    DISEASES. 

Several  loops  of  small  bowel,  which  were  tied  to  one  another  by  a  pseudomembrane, 
had  been  invaded  by  softened  tubercles.  These  were  adherent  to  the  abdominal 
wall  at  the  point  mentioned.  Between  the  umbilicus  posteriorly  and  the  ulcerated 
intestinal  wall  was  an  irregular  cavity,  through  which  fecal  masses  had  passed  out- 
ward into  the  abdominal  cavity.  A  transverse  section  through  the  abdominal 
cavity  at  this  point  allowed  one  to  see  the  intimate  relation  between  the  parietal 
peritoneum,  the  aponeurosis  of  the  trans  versalis,  and  the  recti  muscles.  In  this  case 
the  omentum  and  mesentery  were  matted  together  with  tubercles  in  all  stages. 
The  mesenteric  glands  were  markedly  enlarged  and  some  had  softened.  The  in- 
testinal mucosa  as  a  whole  was  normal,  and.  as  far  as  could  be  seen,  not  ulcerated. 
One  could  readily  see  that  the  perforation  of  the  intestine  had  been  from  without 
inward.  The  mucosa  at  this  point  was  markedly  pigmented  and  infiltrated  with 
blood.  It  was  through  this  cavity  that  the  intestinal  contents  during  life  had  passed 
out  at  the  umbilicus. 

Tuberculosis  of  the  Umbilical  Region.*  —  Case  1.  — 
St.  W.,  aged  six,  was  small  and  gave  evidence  of  having  outgrown  rachitis.  When 
admitted  to  the  hospital  on  April  30th  the  child  showed  marked  emaciation.  The 
abdomen  was  greatly  distended  and  balloon-shaped.  At  the  level  of  the  umbilicus 
the  girth  was  60  cm.  Above  the  symphysis  there  was  dulness  for  a  handbreadth. 
There  was  no  free  fluid  and  no  fever.  The  appetite  was  good.  On  May  16th 
the  patient  complained  of  pain  in  the  lower  abdominal  region,  and  redness  was  noted 
at  the  umbilicus.  Three  days  later  the  reddening  became  marked  and  there  was 
some  fever.  On  May  23d  the  pulse  became  weak  and  the  lower  part  of  the  abdomen 
was  painful.  On  the  twenty-seventh,  in  the  median  line  at  the  umbilicus,  there  was 
noted  a  perforation  from  which  fecal  matter  and  yellow  fluid  escaped.  The  ab- 
dominal measurement  had  diminished.  On  June  3d  the  abdominal  distention  had 
again  increased  somewhat  and  there  was  only  a  slight  discharge.  On  the  seventeenth 
the  patient  felt  hot,  and  an  accurate  examination  could  not  be  made  on  account 
of  severe  pain.  The  discharge  from  the  umbilicus  contained  remnants  of  digested 
food  and  had  an  acid  reaction.  The  patient  suffered  from  diarrhea.  He  died  on 
June  22d. 

At  autopsy,  twenty-four  hours  later,  there  was  a  bluish  discoloration  of  the 
abdominal  wall  and  marked  emaciation.  At  the  umbilicus  was  a  bluish-red  point, 
and  in  the  center  of  this  a  fistulous  opening  the  size  of  a  goose-quill.  When  pressure 
was  exerted  on  the  lower  abdominal  wall,  yellow  fecal  masses  escaped.  A  sound 
could  be  passed  inward  for  2  cm.  The  discoloration  of  the  abdominal  wall  indicated 
a  cavity  which  extended  downward  from  the  umbilicus  and  occupied  the  greater 
part  of  the  lower  abdomen.  It  was  lined  with  reddish  grsiy,  partly  granular  walls, 
which  contained  numerous  nodules.  Through  softened  places  in  the  sac-wall 
a  sound  could  be  passed  into  the  intestinal  lumen.  In  the  posterior  wall  of  the 
cavity  was  a  membrane  which  covered  the  indefinite  intestinal  loops.  The  cavity 
contained  fluid,  solid  fecal  masses,  caseous  products,  and  round  worms.  The  in- 
testinal follicles  were  markedly  swollen  and  here  and  there  ulcerated.  The  mesen- 
teric and  retroperitoneal  glands  were  enlarged,  and  at  certain  points  ulcerated  to 
the  extent  of  perforation. 

*  Ziehl:  Cited  by  Schrotter:  Zur  Kenntnis  der  Tuberculose  der  Nabelgegend.  Arch.  f. 
Kinderheilk.,  1902-03,  xxxv,  398.)  Ueber  die  Bildung  von  Darmfisteln  in  der  vorderen  Bauch- 
wand  infolge  von  Peritonitis  tuberculosa.     Heidelberger  Dissertationschrift,  1881. 


FECAL    FISTULA    AT    THE    UMBILICUS.  325 

Case  2  .  ■ —  K.  A.,  three  years  and  nine  months  old.  In  January  there  was 
vomiting  accompanied  by  swelling  of  the  abdomen.  The  abdomen  was  markedly 
distended,  the  circumference  at  the  umbilicus  being  68  cm.  There  was  tuberculosis 
of  the  lungs,  slight  edema  of  the  lower  extremities,  and  fluid  in  the  lower  abdomen. 
On  March  31st  the  abdominal  girth  was  71  cm.  and  the  inner  abdominal  wall 
appeared  to  be  infiltrated.  On  April  6th  the  child  had  measles,  accompanied  by  a 
mild  cough  without  expectoration.  Nine  days  later  the  skin  beneath  the  umbilicus 
showed  circumscribed  edema.  On  May  8th,  after  the  use  of  santonin,  round  worms 
were  expelled  through  the  rectum.  On  May  9th  it  was  noted  that  the  lower  abdo- 
men was  the  seat  of  what  appeared  to  be  a  rather  large  tumor.  It  began  a  finger- 
breadth  below  the  free  margin  of  the  ribs  on  the  left,  and  extended  within  two  finger- 
breadths  of  the  symphysis.  It  was  resistant  and  had  a  nodular  surface.  The  child 
had  attacks  of  fever  and  chills.  The  stools  were  normal.  On  September  13th 
around  the  umbilicus  were  noted  small  tumors,  which  felt  like  shot.  In  the  hypo- 
gastrium  was  a  definite  tumor  which  impinged  on  the  liver  and  which,  on  the  left, 
was  connected  with  the  umbilical  swelling.  On  October  19th  the  abdomen  was 
painful,  the  umbilicus  ruptured,  and  there  was  an  escape  of  an  abundance  of  puru- 
lent fluid  with  a  fecal  odor.  On  the  following  day  the  flow  of  fluid  still  continued, 
and  the  fistulous  opening  was  the  size  of  a  linseed.  The  abdomen  collapsed  and 
was  very  sensitive;  there  was  diarrhea,  and  the  patient's  appetite  was  very  poor- 
On  the  twenty-sixth  there  was  still  a  free  discharge,  and  a  round  worm  passed 
through  the  fistulous  opening,  the  margins  of  which  were  reddened  and  inflamed. 
On  the  twenty-ninth  there  was  vomiting  of  bitter  masses.  The  skin  was  cool. 
The  child  died  on  October  30th. 

At  autopsy,  thirty-two  hours  later,  the  abdominal  walls  were  of  a  bluish-green 
color.  At  the  umbilicus  was  a  fistulous  opening  into  which  a  sound  could  be  intro- 
duced downward  and  to  the  right;  on  pressure  there  escaped  yellow  masses  with 
a  fecal  odor  and  mixed  with  gas. 

In  the  lower  lobes  of  the  lungs  nodules  were  detected.  The  intestines  were  more 
or  less  firmly  attached  to  the  peritoneum  of  the  anterior  abdominal  wall.  In  the 
umbilical  region  was  a  portion  of  intestine  running  transversely  and  intimately 
attached  to  the  abdominal  wall,  so  that  its  liberation  was  impossible.  These  loops 
communicated  with  the  umbilical  fistula.  The  stomach,  liver,  spleen,  and  large 
and  small  intestine  had  grown  together  and  the  individual  loops  wrere  firmly  adher- 
ent to  one  another.  Between  them  was  a  purulent  exudate.  In  the  intestinal 
serosa  were  numerous  nodules,  but  in  the  mucosa  itself  no  tubercles.  Scattered 
throughout  the  small  intestine  were  numerous  ulcers. 

UMBILICAL  FISTULA  DUE  TO  TUBERCULOSIS  OF  THE  VAS  DEFERENS.* 
While  discussing  the  subject  of  umbilical  diseases  w^th  Dr.  Ramon  Guiteras, 
of  New  York,  he  told  me  of  a  case  of  tuberculosis  of  the  vas  deferens  which  had 
opened  at  the  umbilicus.  I  have  not  found  the  record  of  a  similar  case  in  the  litera- 
ture. Dr.  Guiteras  kindly  sent  me  his  notes  on  the  case.  Although  no  fecal  fistula 
existed,  it  can  be  best  considered  in  this  chapter. 

Umbilical    Fistula    Due    to    Tuberculosis    of    the    Yas 
Deferens. f  —  J.  G.,  an  Italian  laborer  aged  thirty,  was  first  seen  by  Dr. 
*  Although  this  fistula  was  not  fecal  in  character  it  can  be  best  considered  here. 
t  Guiteras,  Ramon:   Personal  communication. 


326  THE    UMBILICUS    AXD    ITS    DISEASES. 

Guiteras  in  the  Columbus  Hospital.  He  was  cachectic  in  appearance,  although  fairly 
well  nourished.  His  breathing  was  more  rapid  than  usual,  owing  to  an  old  pleurisy 
on  the  left  side.  He  entered  the  hospital  on  account  of  suppuration  from  the 
umbilicus.  On  examination  a  probe  entered  a  sinus  an  inch  long  in  the  lower  part 
of  the  umbilicus.  There  was  a  small,  blind  pouch  of  the  same  length  on  the  right 
side  of  the  scrotum,  although  there  was  no  evidence  of  communication  between  the 
two.  The  case  was  a  very  obscure  one.  Dr.  Guiteras  expected  to  find  either  an 
abscess  of  the  urachus  or  necrosis  of  the  under  surface  of  the  pelvic  bone. 

After  the  patient  was  anesthetized,  the  probe,  bent  in  a  certain  way,  was  passed 
downward  and  outward  nearly  to  the  anterior  superior  spine  of  the  ilium.  An  in- 
cision was  made  through  the  abdominal  wall  over  the  point  of  the  probe,  which 
corresponded  to  the  site  of  the  appendix,  and  Dr.  Guiteras  expected  to  find  a  sinus 
leading  to  an  old  appendiceal  abscess;  but  such  was  not  the  case.  He  introduced 
a  probe  through  the  incision  and  found  that  it  extended  down  to  the  inguinal  canal. 
He  then  continued  the  incision  down  to  the  canal,  opened  it,  and  found  that  the 
vas  deferens  was  tuberculous.  A  portion  of  the  diseased  cord  was  excised,  the 
upper  part  of  the  wound  was  closed,  and  the  inguinal  canal  was  packed  and  drained. 
Dr.  Guiteras,  in  referring  to  the  case,  thought  that  he  might  have  to  do  a  more 
extensive  operation  on  the  vas  deferens,  but  ten  days  afterward  the  patient  had  an 
attack  of  apoplexy  and  died  in  three  days. 

LITERATURE  CONSULTED  ON  TUBERCULOUS  PERITONITIS  FOLLOWED  BY  FECAL 

FISTULA  AT  THE  UMBILICUS. 
Baginsky,  A.:    Zur  Demonstration  eines  Praparates.     Verhandl.  der  Berlin,  med.  Gesellschaft, 

Jahrg.  1879-80,  xi,  90. 
Bertherand,  A.:    Observation   d'entero-peritonite   tuberculeuse   avec   perforations   intestinales, 

formation  d'un  reservoir  stercoral  sous  la  paroi  abdominale;    fistule  ombilicale.     Gaz.  med. 

de  Strasbourg,  Xovembre,  1852,  douzieme  annee,  572. 
Catteau,  J.  F.:    De  l'ombilic  et  de  ses  modifications  dans  les  cas  de  distension  de  l'abdomen. 

These  de  Paris,  1876,  Xo.  210. 
Clairmont,  Paul:  Casuistischer  Beitrag  zur  Radicaloperation  der  Kothfistel  und  des  Anus  prae- 
ternaturalis.    Klinik,  Prof.  v.  Eiselsberg,  Konigsberg.  Langenbeck's    Arch.  f.  klin.  Chir., 

1901,  lxiii,  691. 
Crooke,  E.  G. :    On  a  Case  of  Tubercular  Peritonitis  Followed  by  Perforation  of  the  Abdominal 

Parietes.     The  Lancet,  1849,  ii,  668. 
Feulard:  Fistule  ombilicale  et  cancer  de  l'estomae.     Arch.  gen.  de  med.,  1887,  7e  ser.,  xx,  158. 
Fischer,  H. :    Die  Eiterungen  im  subumbilicalen  Raume.     Yolkmann's  Samml.  klin.  Vortrage, 

n.  F.,  Xo.  89  (Chir.  Xr.  24),  Leipzig,  1890-94,  519. 
Heinrich:    Leber  beschrankte  sogenannte  aussere  oder  tuberculose  Peritonitis  bei  Kindern,  oder 

liber  Entziindung  der  Subkutanenschicht  der  Bauchwand  und  fiber  die  Bildung  von  Absces- 

sen  und  Verhartungen  daselbst.     Jour.  f.  Kinderkrankh.,  1849,  xii,  6. 
Nicaise:   Ombilic.     Diet,  eneyclopedique  des  sc.  med.,  Paris,  1881,  2.  ser.,  xv,  140. 
Ledderhose,  L.:    Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Owen,  E.:  Surgical  Diseases  of  Children,  third  ed.,  London,  1897,  269. 
Park,  Roswell:    Clinical  Lecture  on  Congenital  Fistula?  and  Sinuses  at  the  Umbilicus.     Med. 

Fortnightly.  1896,  ix,  9. 
Rachford,  B.  K.:    Artificial  anus    established  spontaneously  through  the  umbilicus.     Arch,  of 

Pediatrics,  viii,  680. 
Richelot,  L.  G:   Abces  tuherculeuxsousombilical.     L'Unionmed.,  1883,  xxxv,  61. 
Rintel:    Ein  Fall  von  Darmtuberculose  mit  Perforation  des  Duodenum  und  Caecum  in's  Cavum 

peritonei.     Berlin,  klin.  Wochenschr.,  1867,  iv,  332. 
Rombeau:    Anus  contre  nature,  suite  de  peritonite.     Bull,  de  la  Soc.  anat.  de  Paris,  1851,  xxvi, 

366. 


FECAL    FISTULA    AT   THE    UMBILICUS.  327 

Scott,  John:    Perforation  of  the  Intestine  with  External  Opening.     Edinburgh  Med.  and  Surg. 

Jour.,  1835,  xliii,  97. 
Schmitz,  A. :   Ueber  Bauchfelltuberculose  der  Kinder.     Jahrb.  f .  Kinderheilk.,  1897,  xliv,  316. 
Schrotter,  E.:     Zur  Kenntnis  der  Tuberculose  der  Nabelgegend.     Arch.  f.  Kinderheilk.,  1902-03, 

xxxv,  398. 
Tillmanns,  H.:  Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durchden  Nabelring  (Ectopia 

ventriculi)  und  tiber  sonstige  Geschwlilste  und  Fisteln  des  Nabels.     Deutsche  Zeitschr.  f. 

Chir.,  1882-83,  xviii,  161. 
Ziehl:   Cited  by  Schrotter. 
Vallin,  E.:    De  rinflammation  periombilicale  dans  la  tuberculisation  du  peritoine.     Arch.  gen. 

de  med.,  1869,  xiii,  558. 


CHAPTER  XXI. 
THE  ESCAPE  OF  ROUND  WORMS  FROM  THE  UMBILICUS. 

Historic  sketch. 

Symptoms. 

Cause  of  the  fistula. 

Treatment. 

Tapeworm  escaping  from  the  umbilicus. 

Detailed  report  of  cases  in  which  round  worms  escaped  from  the  umbilicus. 

The  passage  of  worms  from  the  umbilicus  is  uncommon,  but,  as  pointed  out  by 
Leuckart,  it  is  mentioned  in  the  Hippocratic  writings,  and  in  the  literature  from 
time  to  time  illustrative  cases  have  been  described.  One  of  the  early  ones  was  that 
of  Marteau,  in  1756.  Then  followed  the  articles  of  Hamilton  '(1786),  Ossiander 
(1795),  Poussin  (1817),  Borggreve  (1841),  Hecking  (1842),  v.  Siebold  (1843), 
Nicolich  (1846),  Bottini  (1855),  Richter  (1855),  Bedel  (1856),  Diez  (1858),  Davaine 
(1860),  Weiss  (1868),  Kern  (1874),  Leuckart  (1876),  Nicaise  (1881),  Ledderhose 
(1890),  and  others.  Since  1890  very  little  has  been  written  on  the  subject.  This  is 
but  natural,  as  with  the  perfecting  of  surgical  methods  abdominal  lesions  have,  as  a 
rule,  been  treated  in  the  early  stages,  thus  to  a  large  extent  limiting  the  incidence  of 
fecal  fistulae,  which  were  usually  necessary  for  the  escape  of  worms.  Nevertheless, 
it  must  be  mentioned  that  in  a  few  cases  the  escape  of  worms  from  the  umbilicus 
has  not  been  preceded  by  or  followed  by  that  of  fecal  matter.  The  best  articles 
that  we  possess  on  the  subject  are  those  of  Davaine,  Weiss,  and  Nicaise.  Weiss, 
in  his  inaugural  dissertation,  published  in  Giessen  in  1868,  reports  several  very  inter- 
esting cases  and  then  gives  a  short  historic  sketch. 

Weiss  cites  cases  observed  by  various  authors.  In  Capallaria's  case,  worms 
escaped  from  the  umbilicus.  In  a  case  observed  by  Petrus  Forestus  the  patient  was 
a  woman,  forty  years  of  age,  who  had  a  tumor  at  the  umbilicus.  The  tumor  broke 
and  feces  and  several  worms  escaped.     The  later  history  of  this  patient  is  not  given. 

Frincavello's  patient,  a  boy  five  years  old,  passed  worms  from  the  umbilicus. 
Cladus  reported  the  case  of  a  patient  who  passed  plum-stones  and  worms  from  the 
umbilicus. 

Creulin's  patient  was  a  girl  who  had  an  umbilical  tumor,  which  ruptured  and 
three  worms  escaped  from  it.     Healing  followed. 

Boire's  patient  was  a  young  girl  from  whose  umbilicus  seven  worms  escaped. 

Weiss  next  reports  the  observations  of  Hamilton  and  Dregogirone,  made  on 
small  children.  In  these  cases  worms  escaped  from  the  umbilicus.  Weiss  says 
that  similar  observations  had  been  made  by  Pouspin*  and  by  Cappola.  He  then 
refers  to  a  report  by  Beilman,f  under  whose  observation  was  a  child  that  vomited 
worms.  They  also  escaped  by  the  rectum  and  from  an  abscess  at  the  umbilicus. 
Weiss  further  mentions  that  similar  cases  had  come  under  the  observation  of  Paul 
of  iEgina,  Alix  Trailer,  Avicenna,  Feli-Plater,  and  Bianchi. 

*  Pouspin:  Jour,  de  Corvisart,  1817,  xi.  f  Beilman:  Bull.  d.  sc.  med.,  1831,  xxv. 

328 


THE    ESCAPE    OF    ROUND    WORMS    FROM    THE    UMBILICUS.  329 

Finally  he  reports  the  observation  of  Ambroise  Pare.  The  patient  was  a  woman 
who  had  an  ulcer  at  the  umbilicus,  from  which  a  number  of  worms  escaped.  The 
fistula  remained  open  for  a  long  time,  and  a  fecal  discharge  persisted.  Finally  it 
closed  and  healing  took  place. 

SYMPTOMS. 

The  majority  of  these  patients  have  symptoms  of  a  gastro-intestinal  disturbance, 
and  after  a  period  varying  from  a  few  days  to  a  couple  of  weeks  develop  a  soreness 
at  the  umbilicus.  The  center  of  the  umbilicus  gradually  becomes  softened,  and  the 
surrounding  portions  are  thickened  and  edematous.  In  Sanchez'  case  the  swelling 
became  as  large  as  a  child's  head. 

In  the  course  of  a  few  days,  usually  as  result  of  the  use  of  poultices,  the  abscess 
breaks  and  there  is  an  escape  of  pus.  Sometimes  this  is  accompanied  by  fecal 
matter  or  round  worms  or  both;  occasionally  fecal  matter  is  not  detected  at  all, 
the  wound  closing  up  after  the  pus  and  worms  have  escaped.  The  worms  may  be 
alive  or  dead.  Occasionally  only  one  worm  escapes,  but,  as  a  rule,  several  come 
away  at  once.  Closure  of  the  wound  may  occur  temporarily,  only  to  be  followed 
by  more  pain  and  the  expulsion  of  more  worms. 

In  two  cases,  those  of  Beilman  and  Heer,  cited  by  Weiss,  the  patients  not  only 
passed  round  worms  by  the  umbilicus  and  the  bowel,  but  also  vomited  them. 

The  majority  of  the  patients  recover,  but  the  outcome  depends  in  a  large  measure 
on  the  cause  of  the  fistula. 

CAUSE  OF  THE  FISTULA. 

Davaine,  in  his  excellent  work  published  in  1860,  gives  a  table  of  47  cases  in  which 
worms  passed  through  the  abdominal  wall.  According  to  these  figures,  the  point 
of  exit  was:  the  umbilicus  in  19  cases;  the  groin  in  21  cases;  other  regions  in  7 
cases — thus  demonstrating  that  it  is  at  the  points,  where  hernia?  are  most  prone  to 
occur,  that  worms  escape. 

He  also  draws  attention  to  the  fact  that  in  children  the  worms  usually  escape 
from  the  umbilicus,  whereas  in  adults  the  inguinal  region  is  the  most  common  site 
of  exit.     His  table  gives  the  following: 

From  the  umbilicus  in  patients  less  than  fifteen  years  of  age 15  cases 

From  the  umbilicus  in  patients  more  than  fifteen  years  of  age 4  cases 

From  the  inguinal  region  in  patients  less  than  fifteen  years  of  age 2  cases 

From  the  inguinal  region  in  patients  more  than  fifteen  years  of  age ...  19  cases 

The  reason  for  this  difference  is  obvious:  in  the  child  the  umbilicus  represents 
the  weakest  point  in  the  abdominal  wall,  but  as  the  child  develops  into  adult  life 
the  umbilicus  usually  becomes  firmly  knit  and  the  inguinal  region  is  the  area  most 
prone  to  give  way. 

Where  tuberculosis  of  the  intestine  exists,  it  is  readily  seen  that  an  ulcerated 
area  may  become  adherent  to  the  umbilicus  and  that,  with  masses  of  round  worms 
lying  in  the  intestine,  these  might  readily  injure  the  friable  walls,  causing  an  abscess 
and  the  escape  of  fecal  matter  from  the  umbilicus.  Again,  where  typhoid  fever  has 
recently  been  present,  as  in  Diez's  case,  the  ulceration  may  have  extended  deep 
into  the  intestinal  wall,  thus  rendering  the  outer  or  peritoneal  surface  of  the  intes- 
tine liable  to  become  adherent  to  the  surrounding  structures.  If  it  becomes  ad- 
herent to  the  umbilicus,  abscess  formation  might  readily  occur.     We  have,  however, 


330  THE    UMBILICUS    AND    ITS    DISEASES. 

only  one  example  of  such  an  occurrence.  In  the  majority  of  the  cases  the  patient 
first  had  gastro-enteric  symptoms,  which  were  followed  by  localized  tenderness  at 
the  umbilicus. 

In  the  older  literature  a  spirited  controversy  arose  as  to  whether  the  lumbri- 
coid  worm  could  penetrate  the  normal  intestinal  wall,  some  claiming  that  it  could, 
others  that  it  was  not  capable  of  doing  so.  Davaine,  from  his  observations,  con- 
cluded that  lumbricoids  do  not  perforate  the  healthy  intestine,  but  he  would  not 
deny  that  a  soft,  ulcerated  intestine  might  yield  and  perforate  as  a  result  of  pressure 
exerted  by  the  head  of  the  Ascaris  lumbricoides. 

If  a  large  fecal  concretion  is  capable  of  causing  ulceration  and  perforation  of  the 
intestine,  it  does  not  seem  difficult  to  understand  how  masses  of  round  worms  might 
cause  ulceration  of  the  intestine  with  subsequent  perforation. 

In  the  cases  reported  by  Hamilton,  Poussin,  and  MacSwiney,  the  previous  his- 
tories were  strongly  suggestive  of  the  existence  of  a  patent  omphalomesenteric 
duct.  In  such  cases  it  was  only  natural  that  the  worms  should  escape  along  the 
preexisting  fistulous  tract  to  the  umbilicus.  In  some  cases  the  patent  omphalo- 
mesenteric duct  was  so  small  that  no  fecal  matter  escaped  until  a  worm  was  seen 
projecting  through  the  umbilicus  or  was  noted  crawling  on  the  abdomen. 

TREATMENT. 

This  will,  of  course,  depend  on  the  cause  of  the  fistula.  As  will  be  seen  from  a 
study  of  the  appended  histories,  worms  were  expelled  from  time  to  time.  Accord- 
ingly, it  will  be  advisable,  after  the  patient  has  gained  in  strength,  to  give  an  anthel- 
mintic. "When  the  bowel  shows  no  further  trace  of  worms,  and  when  the  umbilical 
induration  has  disappeared,  nothing  but  a  fistulous  tract  remaining,  the  abdomen 
should  be  opened  and  the  hole  in  the  bowel  closed.  If  a  patent  omphalomesenteric 
duct  has  been  the  cause  of  the  fistula,  it  can  readily  be  removed,  the  same  technic 
being  employed  as  for  an  appendix  operation.  If  the  previous  history  suggests  an 
appendix  abscess  with  escape  of  feces,  abscess  formation,  and  the  escape  of  its 
contents  through  the  umbilicus,  the  appendix  region  should  also  be  explored,  pro- 
vided the  dangers  of  a  general  peritoneal  contamination  are  not  too  great. 

In  some  of  those  cases,  in  which  the  worms  seemed  to  escape  from  an  intestinal 
loop  which  had  become  directly  adherent  to  the  umbilicus,  the  wound  closed  spon- 
taneously after  all  the  worms  had  been  expelled.  Where  a  fistula  still  persists,  it 
can  be  readily  closed  by  operation.  In  case  the  perforation  has  been  followed  by 
an  abdominal  abscess  and  this  has  later  opened  at  the  umbilicus,  the  bowel  opening 
at  the  bottom  of  an  abscess  may  be  lined  with  granulation  tissue.  In  such  a  case 
closure  of  the  hole  in  the  bowel  is  not  only  a  difficult  procedure,  but,  on  account 
of  the  necessary  drainage,  is  apt  to  be  followed  by  failure  or  by  a  general  peritonitis. 

In  those  cases  in  which  the  fecal  fistula  is  of  tuberculous  origin,  one  should  hesi- 
tate long  before  attempting  to  close  it,  as  on  account  of  the  friable  character  of  the 
tissues  the  end-result  may  be  worse  than  that  present  at  the  time  of  operation. 

TAPEWORMS  ESCAPING  FROM  THE  UMBILICUS. 
From  the  foregoing  we  have  seen  that  round  worms  may  occasionally  escape 
from  the  umbilicus.     If  a  fecal  fistula  exists  in  this  situation  and  the  intestine  con- 
tains a  tapeworm,  there  is  no  reason  why  it  should  not  escape  in  a  similar  manner. 


THE    ESCAPE    OF    ROUND    WORMS    FROM    THE    UMBILICUS.  331 

Siebold,  in  1843,  reported  such  a  case.  In  April,  1841,  Siebold  saw  at  the  clinic 
in  Erlangen  a  man,  aged  twenty-two,  who  had  had  scrofula  in  childhood  and  who  had 
had  numerous  abscesses.  At  the  umbilicus  was  an  elevation.  One  day,  after  the 
patient  had  been  given  a  certain  decoction,  a  physician  was  called  because  there 
was  something  alive  at  the  umbilicus.  Six  inches  of  a  taenia  solium  were  protrud- 
ing from  the  umbilical  opening.  Traction  was  exerted,  and  the  head  came  away. 
Several  meters  of  the  lower  portion  were  drawn  out;  in  other  words,  the  entire 
worm  was  extracted  with  ease.  No  fecal  matter  or  gas  escaped.  The  man  did  not 
improve,  but  died  of  pulmonary  tuberculosis. 

Richter,  in  1855,  reported  a  case  in  which  a  tapeworm  escaped  from  the  an- 
terior abdominal  wall.  A  man,  thirty  years  of  age,  had  had  an  abdominal  inflamma- 
tion of  unknown  origin.  Poultices  were  applied  for  months,  and  an  abscess  de- 
veloped in  the  abdominal  wall  to  the  right  of  the  mid-line.  A  fistulous  tract  passed 
upward  toward  the  liver.  The  fistula  discharged  pus.  Feces  were  never  observed. 
From  time  to  time  living  portions  of  tapeworms,  however,  escaped. 

Tillmanns,  in  his  article  on  Congenital  Prolapsus  of  the  Stomach  Mucosa 
through  the  Umbilicus,  says  that  v.  Siebold  had  spoken  of  two  cases  in  which 
tapeworms  had  escaped  through  the  abdominal  wall.  One  case  was  reported  by 
Monleng,  and  the  condition  was  associated  with  a  definite  fecal  fistula.  The  second 
was  reported  by  Sporing.  [We  have  the  record  of  only  one  case,  namely,  that  of 
Siebold,  in  which  a  tapeworm  escaped  from  the  umbilicus  itself.] 

DETAILED  REPORT  OF  CASES  IN  WHICH  ROUNDWORMS  ESCAPED  FROM  THE 

UMBILICUS.* 

Escape  of  Round  Worms  From  the  Umbilicus.f — Bedel 
mentions  two  cases  related  to  him  by  his  uncle,  Dr.  Bedel.  The  patients  were  two 
brothers,  one  eleven,  the  other  thirteen.  Each  passed  round  worms  from  the 
umbilicus  within  one  month. 

Escape  of  Round  Worms  From  the  Umbilicus. t  —  The 
patient  was  a  boy,  four  years  old.  The  umbilicus  had  been  transformed  into  a 
"pus-bladder,"  and  around  it  was  a  reddening.  When  the  child  was  put  to  bed  for 
examination,  he  turned  suddenly  and  the  abscess  broke.  A  worm  was  found  pro- 
jecting from  the  umbilicus.  The  next  day  the  family  showed  the  doctor  three 
more  worms.  With  the  use  of  bandages  and  applications  of  carbolic  acid  the  wound 
healed.     Berner  thought  there  must  have  been  a  diverticulum  in  this  case. 

Escape  of  a  Worm  Through  the  Umbilicus.  — ■  Weiss  § 
reports  a  case  observed  by  Blanchet.||  An  adult  male  had  severe  pain  in  the  um- 
bilical region.  The  umbilicus  commenced  to  increase  in  size,  and  eight  days  later 
fluctuation  was  detected.  At  the  most  prominent  part  of  the  tumor  a  painful  dark 
point  developed.  The  abscess  was  opened,  and  much  fluid  and  one  worm  escaped. 
Fourteen  days  later  the  wound  had  healed  completely. 

*  I  wish  to  express  my  thanks  to  Dr.  Charles  W.  Stiles,  of  Washington,  for  his  kindness  in 
supplying  me  with  the  more  recent  references  on  this  subject. 

t  Bedel:  Bull,  de  therapeutique,  1856,  li,  550. 

J  Berner,  H. :  Entleerung  von  Spulwiirmern  aus  dem  Nabel.  Aerztliches  Intelligenzbl., 
Miinchen,  1876,  xxiii,  238. 

§  Blanchet  (Cited  by  E.  Weiss) :  Ueber  diverticular  Nabelhernien  und  die  aus  ihnen  her- 
vorgehenden  Nabelfisteln.     Inaug.  Diss.,  Giessen,  1868. 

||  Blanchet:  Acad,  med.,  Paris,  1827. 


332  THE    UMBILICUS    AND    ITS    DISEASES. 

Escape  of  Round  Worms  Through  the  Umbilicus.  — ■ 
In  1833  Borggreve*  saw  a  five-year-old  boy  who,  for  fourteen  days,  had  had  pain 
in  the  umbilical  region  associated  with  general  symptoms  suggesting  worms. 
Examination  later  showed  an  opening  at  the  umbilicus,  and  projecting  from  this 
was  the  snout  of  a  round  worm.  The  worm  was  carefully  grasped  with  forceps 
and  drawn  out.  It  was  eight  inches  in  length.  An  appropriate  vermifuge  was 
given,  and  21  large  worms  passed  from  the  umbilicus  and  five  from  the  rectum. 
The  umbilical  opening  later  closed  spontaneously. 

Escape  of  Round  Worms  Through  the  Umbilicus,  f- — 
A  ten-year-old  boy,  who  had  always  been  healthy,  developed  severe  gastro-enteritis. 
On  the  fourth  day  the  umbilical  region  was  raised  and  surrounded  by  a  red  zone. 
Warm  applications  were  made.  The  umbilicus  opened,  and  three  round  worms 
escaped.  Two  more  came  away  from  the  umbilicus  the  same  evening.  On  the 
fifth  day  the  general  symptoms  disappeared  and  feces  escaped  from  the  opening. 
A  compression  bandage  and  frequent  cauterization  brought  about  healing  in  one 
month. 

Escape  of  Round  Worms  From  the  Umbilicus.  — ■  CasaliJ 
reports  a  case  in  which  round  worms  escaped  from  the  umbilicus. 

Escape  of  Worms  From  the  Umbilicus.  §  —  A  woman,  sixty 
years  of  age,  had  had  symptoms  of  enteritis.  An  abscess  developed  at  the  umbili- 
cus and  36  worms  escaped.  Weiss,  when  speaking  of  this  case,  compares  the  obser- 
vation to  those  of  Borggreve,  Glos,  Bottini,  Diez,  and  Finger. 

Round  Worms  at  the  Umbilicus.  ||  —  A  nine-year-old  girl, 
in  April,  1855,  had  a  severe  attack  of  typhoid  fever,  and  during  convalescence  a 
small  tumor  developed  at  the  umbilicus.  Its  formation  was  accompanied  by  much 
pain,  and  the  skin  was  red.  Poultices  were  applied,  and  pus  having  the  odor  of 
feces  escaped.  There  was  no  doubt  that  the  abscess  communicated  with  the  bowel. 
Daily  applications  of  caustics  caused  the  opening  to  close  in  fourteen  days.  Nine 
months  later  the  child  had  sudden  pain  and  the  umbilicus  opened  in  a  few  hours. 
A  live  round  worm  appeared.  This  was  pulled  out,  its  removal  occasioning 
much  pain.  In  the  course  of  the  next  fourteen  days  nine  more  worms  came  away. 
The  opening  then  closed  without  treatment. 

In  1857  the  umbilicus,  which  in  the  mean  time  had  been  closed,  again  opened, 
and  in  three  days  nine  live  round  worms  escaped.  After  the  giving  of  appro- 
priate medicine  six  more  worms  were  passed,  this  time  by  the  rectum.  The  fistula 
closed  and  gave  no  further  trouble. 

Escape  of  Worms  From  the  Umbilicus.  —  Weiss**  gives  a 
description  of  a  case  reported  by  Girone. ft  A  fourteen-year-old  boy  had  suffered 
for  some  time  with  tabes  mesenterica  and  was  confined  to  bed.  His  abdomen  was 
swollen  and  he  had  fever.     For  one  year  he  complained  of  pain  in  the  side.     The 

*  Borggreve:  Abgang  von  Spulwiirmern  durch  den  Nabel.  Medicinische  Zeitung.  1841, 
x,  117. 

t  Bottini,  G.  D.:  Schmidt's  Jahrbuch,  1855,  lxxxv,  308. 

%  Casali,  T.:  Un  caso  di  elmintiasi  con  fuorinscita  di  ascaridi  lombricoidi  dah"  ombellico. 
II  Raccoglitore  medico,  1879,  serie  iv,  xii,  281. 

§  Denaire  (Cited  by  E.  Weiss) :  Op.  cit.,  obs.  4. 

J|  Diez:  Spulwiirmer  im  Nabel.  Med.  Correspondenz-Bl.  des  Wurtemberg.  aerztlichen 
Vereins,  Stuttgart,  1858,  xxviii,  95. 

**  Girone:  Cited  by  E.  Weiss,  op.  cit.,  1868.  ft  Girone:  Gaz.  med.  de  Paris,  1838,  p.  231. 


THE    ESCAPE    OF    ROUND    WORMS    FROM    THE    UMBILICUS.  333 

urine  was  cloudy  and  the  stools  liquid.  The  pains  gradually  increased,  and  finally 
an  abscess  appeared  at  the  umbilicus,  which  opened  spontaneously,  and  four  round 
worms  escaped.  Fecal  matter  also  came  from  the  fistulous  tract.  The  opening 
closed  completely. 

A  Case  of  Worms  Escaping  Through  an  Opening  at 
the  Navel.  —  According  to  Simmons,  Hamilton*  made  the  following  report 
in  a  letter :  A  male  child,  a  year  and  a  half  old,  was  thought  by  the  mother  for  several 
weeks  to  have  had  worms.  The  umbilicus  protruded  about  an  inch  and  appeared 
inflamed.  The  mother  said  that  the  person  who  had  cared  for  the  child  for  a 
few  days  after  its  birth  drew  the  bandage  from  the  umbilicus  too  suddenly,  and 
with  the  bandage  the  remains  of  the  cord,  before  it  had  been  completely  separated. 
She  added  that,  though  the  part  healed,  it  had  always  remained  tender.  To  pre- 
vent its  protruding  too  much,  a  bandage  had  been  applied  pretty  tightly  over  it. 
Soon  after  that  the  child  seemed  to  have  symptoms  of  worms,  and  on  untying 
the  bandage  the  mother  observed  a  worm  about  seven  inches  long  crawling  over  the 
abdomen.  In  the  middle  of  the  umbilicus  were  two  small  holes,  out  of  one  of  which 
the  worm  had  just  issued.  Before  long  two  more  came  away  through  the  same 
opening.  One  of  the  worms  had  protruded  itself  two  inches  when  she  pulled  it 
away  with  the  fingers.  The  next  day  two  more  worms  came  away.  All  of  these 
were  six  to  eight  inches  long  and  alive  when  they  escaped.  At  the  end  of  ten  days 
six  more  came  away  in  the  course  of  twenty-four  hours.  In  the  succeeding  five 
weeks  no  more  had  escaped  and  the  opening  had  closed.  The  umbilicus  was  the 
size  of  a  walnut,  and  evidently  diseased,  but  the  child  continued  well. 

Escape  of  Round  Worms  Through  a  Fecal  Fistula  at 
the  Umbilicus. f  —  Weiss  mentions  a  case  recorded  by  Heer.i  A  young 
girl  vomited  worms  and  also  passed  them  by  the  bowel.  An  abscess  developed  at  the 
umbilicus.  This  was  opened,  and  a  round  worm  escaped.  Healing  soon  took  place. 
Escape  of  Round  Worms  From  the  Umbilicus. §  —  A 
four-year-old  girl  for  eight  days  had  been  complaining  of  an  inflammatory  swell- 
ing at  the  umbilicus.  After  the  application  of  poultices  the  swelling  opened  and 
there  escaped  a  foul-smelling  pus,  together  with  three  dead  round  worms.  In  a 
few  days  the  umbilical  opening  closed  and  the  child  recovered.  Two  months  later 
she  was  again  ill  with  symptoms  of  worms.  The  umbilicus  again  became  promi- 
nent and  inflamed,  opened,  and  discharged  several  more  worms.  The  wound  closed, 
and  thereafter  there  were  no  further  signs  of  worms. 

Escape  of  Worms  From  the  Umbilicus. ||  —  The  patient  was 
a  seven-year-old  boy  who  complained  of  pain  in  the  lower  abdomen.  An  umbilical 
abscess  developed,  and  from  it  there  escaped  41  round  worms.  The  opening  closed. 
Four  months  later  it  opened  again  and  11  worms  escaped.  The  colic  disappeared; 
nevertheless,  no  closure  took  place  and  a  fecal  fistula  developed. 

Extraction  of  Ascaris  Lumbricoides  From  the  Um- 
bilicus.** —  A  boy,  four  years  of  age,  had  been  in  good  health  until  five  months 

*  Hamilton,  Robert:  London  Med.  Jour.,  1786,  vii,  372. 

t  Heer:   Cited  by  E.  Weiss,  op.  cit.  %  Heer:   Revue  med.,  1837. 

§  Hecking:     Entleerung   von   Spulwurmern   durch   den   Xabel.     Generalber.    des    Konigl. 
Rheinischen  med.  Coll.  fur  1839,  Coblenz,  1842,  80. 
||  Lini:   Cited  by  E.  Weiss,  op.  cit.,  p.  13. 
**  Macphail,  Donald:   Glasgow  Med.  Jour.,  1884,  xxii,  382. 


334  THE    UMBILICUS    AND    ITS    DISEASES. 

before  admission.  Shortly  before  coming  under  observation  he  had  been  treated 
for  thread-worms.  Five  months  before  admission  he  had  become  restless,  listless, 
cross,  and  had  had  diarrhea.  The  abdomen  was  swollen  and  tender  and  emacia- 
tion was  noted.  The  condition  gradually  grew  worse.  The  abdomen  became 
prominent  and  tense,  and  the  superficial  veins  were  much  enlarged.  He  was  very 
weak,  emaciated,  and  apathetic.  The  diarrhea  was  severe,  and  there  was  sweating 
every  night.  At  this  time  a  thin,  watery  pus  commenced  to  escape  from  the  umbili- 
cus. This  was  very  offensive,  but  had  no  fecal  odor.  During  the  next  three  weeks 
the  condition  was  still  worse;  the  discharge  from  the  umbilicus  became  more 
abundant  and  excoriating.  Later  there  was  difficulty  in  micturition,  with  retrac- 
tion of  the  testicles.  Between  the  umbilicus  and  the  pubes  was  a  diffuse,  slightly 
elevated  swelling,  which  was  very  tender,  but  there  was  no  redness.  A  few  days 
later  the  child  was  almost  moribund,  and  there  was  edema  of  the  feet  and  legs. 
Protruding  from  the  umbilicus  were  two  inches  of  a  wriggling  round  worm  which 
was  easily  drawn  out.  It  was  nine  inches  long.  There  was  rapid  improvement 
in  the  child,  but  he  was  still  very  thin.  When  the  case  was  reported  before  the 
medical  society,  the  possibility  of  an  open  omphalomesenteric  duct  was  considered. 

The  Passage  of  Chyle  and  Worms  From  the  Umbili- 
cus.*'—  The  patient  was  a  girl  seven  years  old.  She  had  a  well-marked  ascites. 
There  was  a  historj^  of  ascites  on  previous  occasions.  When  two  years  of  age  she 
had  ascites,  which  disappeared  in  three  months.  A  few  months  before  Marteau 
saw  her  ascites  again  developed.  On  admission  there  was  a  hard  and  inflamed 
tumor  at  the  umbilicus.  After  the  application  of  poultices  the  swelling  became 
circumscribed  and  opened.  Escaping  with  the  pus  were  three  lumbricoid  worms. 
Following  these,  chylous  material  escaped.  The  opening  persisted  for  six  months 
and  discharged  pus,  chyle,  and  pieces  of  undigested  food,  and  from  time  to  time 
round  worms  escaped.  After  six  months  the  tract  cicatrized,  and  thereafter  there 
was  nothing  but  a  thin  serous  discharge.  The  child  was  well  nourished.  The 
exact  cause  of  the  trouble  was  impossible  to  determine. 

Ascaris  Lumbricoides  Extracted  From  an  Umbili- 
cal Fistula,  t  —  A  boy,  seven  years  old,  came  to  the  hospital  with  an  ascaris 
lumbricoides  projecting  two  and  one-half  inches  from  the  umbilicus.  "I  at  once 
proceeded  to  deliver  it  in  an  artistic  way,  and  I  had  to  exercise  some  caution  in  the 
operation  lest  it  should  break,  as  there  was  considerable  tension  on  the  creature, 
and  it  was  evident  that  its  body  was  tightly  compressed  in  a  track  or  sinus,  through 
which  it  was  slowly  making  its  way  out."  The  father  of  the  boy  stated  that  since 
birth  there  had  been  a  fistula  at  the  umbilicus,  and  that  it  had  constantly  dis- 
charged. There  were  never,  however,  any  signs  of  blood,  bile,  or  feces.  The  dis- 
charge was  clear  yellow  matter  with  no  feculent  odor.  MacSwiney  says  his  friend, 
Dr.  Kelly,  thought  the  fistula  was  due  to  an  unclosed  vitelline  duct. 

Escape  of  Round  Worms  From  the  Umbilicus. J  —  A 
woi i j an,  twenty-five  years  of  age,  who  had  had  two  normal  labors,  complained  of 
severe  pain  in  the  hypogastric  region  shortly  after  the  second  labor.  The  menses 
ceased,  and  the  physician  thought  a  new  pregnancy  was  under  way.     Finally  the 

*  Marteau:  Sur  une  ouverture  a  1'ombilic  qui  donnoit  passage  au  chyle  et  a  des  vers  con- 
tenus  dans les intestins  greles.     Jour,  demed.,  Paris,  1756,  v,  100. 

+  MacSwiney,  S.  M.:  Proc.  Path.  Soc.  of  Dublin,  1873-75,  vi,  251. 

%  Nicolich:  Abgang  von  Spulwurmern  aus  dem  Nabel.  Schmidt's  Jahrbuch,  1846,  1,  53 
(translated  from  Gaz.  di  Milano,  Xo.  11,  1845). 


THE    ESCAPE    OF    ROUND    WORMS    FROM    THE    UMBILICUS.  335 

abdominal  wall  from  the  umbilicus  to  the  symphysis  became  bright  red.  Applica- 
tions were  made,  and  the  umbilicus  opened.  There  was  an  escape  of  a  moderate 
amount  of  foul-smelling  pus,  but  no  fecal  masses.  Several  days  later  three  round 
worms  escaped,  and  a  few  days  after  this  six  more  worms  passed  from  the  umbilicus. 
The  pain  became  pronounced  in  the  inguinal  regions,  and  pressure  here  caused  a 
moderate  amount  of  pus  to  escape  from  the  umbilicus. 

Fecal  Fistula  at  the  Umbilicus.*  —  The  patient  was  a  delicate 
boy  who  had  previously  passed  lumbricoid  worms.  Toward  the  end  of  1795  he 
complained  of  abdominal  pain.  There  was  distention  and  an  area  of  inflammation 
at  the  umbilicus  which  seemed  ready  to  rupture.  The  tumor,  however,  gradually  re- 
ceded. In  March,  1796,  the  patient  developed  a  severe  cough.  Before  Easter  the 
abdomen  again  became  distended,  and  the  umbilicus  was  very  prominent,  red,  and 
painful.  The  skin  was  glistening  and  distended,  and  there  was  a  marked  degree  of 
emaciation.  On  March  31st  there  was  a  rupture,  with  the  escape  of  pale  yellow,  fetid 
fecal  masses.  The  boy  died  on  April  4,  1796.  At  autopsy  the  abdomen  was  found 
distended.  The  opening  at  the  umbilicus  was  sealed  up  with  dry  pus.  The  peri- 
toneum contained  many  small  and  large  nodules,  and  from  several  openings  beneath 
the  stomach  region  four  live  round  worms  came  away.  The  larger  opening  ad- 
mitted the  index-finger  and  was  on  the  right,  beneath  the  liver.  Attached  to  the 
umbilicus  was  an  intestinal  loop,  and  from  this  pus  had  escaped.  The  mesenteric 
glands  were  enlarged  and  hardened. 

Escape  of  Several  Round  Worms  From  the  Umbili- 
cus .  f  —  The  patient  was  a  boy,  three  years  of  age,  and  of  healthy  parentage. 
The  nurse  made  traction  on  the  cord  on  the  fifth  day,  as  it  had  not  come  away. 
"Inflammation"  followed,  and  a  small  opening  developed.  Sometimes  this  would 
close  for  three  weeks  or  a  month,  but  never  for  a  longer  period.  On  examination 
the  mother  was  surprised  to  see  a  worm  half  an  inch  long  crawling  along  the 
abdomen.  The  child,  who  had  been  sick,  rapidly  recovered.  Several  weeks  later 
two  worms  similar  in  character  were  extracted  from  the  umbilical  fistula.  In  the 
intervals  between  the  times  of  abdominal  pain  the  child  enjoyed  good  health, 
except  for  an  occasional  discomfort  due  to  worms.  At  the  umbilicus  was  a  slight 
projection  the  size  of  a  chestnut  with  an  opening  in  the  center.  Escaping  from 
this  were  contents  resembling  feces.  On  several  occasions  the  physician  was 
called  to  see  the  child  when  in  great  pain,  and  removed  lumbricoid  worms  from 
the  fistula.     Some  of  these  worms  reached  four  and  one-half  inches  in  length. 

[The  history  is  strongly  indicative  of  a  patent  omphalomesenteric  duct.] 

Round  Worms  Escaping  From  the  Abdomen.  —  Richter| 
speaks  of  cases  reported  by  Baumann,  and  one  by  Winterich,  in  which  round 
worms  were  passed  at  the  umbilicus,  and  says  that  such  an  occurrence  is  not  rare. 

Escape  of  Round  Worms  From  a  Fecal  Fistula  at  the 
Umbilicus.  §  —  This  case  came  under  the  observation  of  Sanchez. ||  The 
patient  was  a  woman  who  developed  a  tumor  at  the  umbilicus.     After  two  years 

*  Ossiander:  Neue  Denkwlirdigkeiten  ftir  Aerzte  und  Geburtshelfer,  i,  2.  Abtheilung. 
Cited  by  Schrotter. 

t  Poussin :  Observation  sur  1' expulsion  de  l'abdomen  par  une  ouverture  a  l'ombilic  de  plusieurs 
vers  ascarides-lombricoides.     Jour,  de  rued.,  1817,  xl,  81. 

t  Richter:  Bandwurmglieder  aus  einer  Bauchfistel  entleert.  Schmidt's  Jahrbuch,  1855, 
lxxxv,  308. 

§  Sanchez:  Cited  by  E.  Weiss,  op.  cit.,  obs.  3. 

||  Sanchez:   Gaz.  Med.  Italiana,  1862,  v.  284. 


336  THE    UMBILICUS    AND    ITS    DISEASES. 

this  formed  an  abscess  and  a  fecal  fistula  developed,  from  which  three  worms 
escaped.  When  St.  Sardi  saw  the  patient,  the  tumor  at  the  umbilicus  was  the  size 
of  a  child's  head.  Pus  flowed  from  it  without  any  diminution  in  size  of  the  tumor. 
With  a  probe  an  intestinal  stone  could  be  felt.  This  was  removed  at  operation. 
The  nucleus  of  the  stone  consisted  of  hardened  feces  and  was  covered  over  with 
earthy  phosphates.     The  patient  died  fourteen  days  after  operation. 

A  Round  Worm  at  the  Umbilicus.  —  Weiss*  says  that  in  the 
Journal  de  Progres,  1834,  the  case  of  a  sixteen-year-old  negro  was  recorded.  The 
patient  had  a  phlegmonous  tumor  at  the  umbilicus,  and  gave  a  history  of  having 
passed  92  worms  at  stool.  The  tumor  was  opened,  and  in  it  was  found  a  half- 
digested  worm. 

*  Weiss,  E.:   Op.  cit. 

LITERATURE  CONSULTED  ON  THE  ESCAPE  OF  WORMS  FROM  THE  UMBILICUS. 

Bedel:  Bull,  de  therapeutique,  1856,  li,  550. 

Berner,  H.:    Entleerung  von  Spulwurmern  aus  dem  Nabel.  Aerztliches  Intelligenzbl.,  Munchen, 

1876,  xxiii,  238. 
Borggreve:  Abgang  von  Spulwtirmern  durch  den  Nabel.     Med.  Zeitung,  1841,  x,  117. 
Bottini,  G.  D. :  Schmidt's  Jahrbuch,  1855,  lxxxv,  308. 
Casali,  T.:   Un  caso  di  elmintiasi  con  fuorinscita  di  ascaridi  lombricoidi  dall'  ombellico.     HRac- 

coglitore  medico,  1879,  ser.  iv,  xii,  281. 
Davaine,  C. :  Traite  des  entozoaires,  Paris,  1860,  115. 
Diez:    Spulwiirmer  im  Nabel.     Med.  Correspondenzbl.  des  Wurtemberg.  aerztlichen  Vereins, 

Stuttgart,  1858,  xxviii,  95. 
Hamilton:  Case  of  Worms  Discharged  through  an  Opening  in  the  Navel.    London  Med.  Jour., 

1786,  vii,  372. 
Hecking:    Entleerung  von  Spulwurmern  durch  den  Nabel.     Generalbericht  des  Konigl.  Rhei- 

nischen  med.  Coll.  f.  1839,  Coblenz,  1842,  80. 
Kern,  Theo.:  Ueber  die  Divertikel  des  Darmkanals.     Inaug.  Diss.,  Tubingen,  1874. 
Ledderhose,  G.:    Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Leuckart,  R.:    Die  menschlichen  Parasiten  und  die   von  ihnen  hervorgehenden    Krankheiten. 

Leipzig,  1876,  ii,  241. 
Macphail,  Donald:   Ascaris  Lumbricoides  Extracted  from  the  Umbilicus.     Glasgow  Med.  Jour., 

1884,  xxii,  382. 
MacSwiney,  S.  M.:  Proc.  Path.  Soc.  of  Dublin,  1873-75,  vi,  251. 
Marteau:   Sur  une  ouverture  a  l'ombilic,  qui  donnoit  passage  au  chyle  et  a  des  vers  contenus 

dans  les  intestins  greles.     Jour,  de  med.,  Paris,  1756,  v,  100. 
Nicaise:    Ombilic.     Dictionnaire  encyclopedique  des  sc.  med.,  Paris,  1881,  2  ser.,  xv,  140. 
Nicolich :   Abgang  von  Spulwurmern  aus  dem  Nabel.     Schmidt's  Jahrbuch,  1846,  1,  53.     (Trans- 
lated from  Gaz.  di  Milano,  No.  11,  1845.) 
Ossiander,  F.  B.:    Original  not  located.     Neue  Denkwiirdigkeiten  fur  Aerzte  und  Geburtshelfer, 

i,  2.  Abtheilung.     Reported  by  Schrotter. — Schrotter,  E.:    Zur  Kenntnis  der  Tuberculose 

der  Nabelgegend.     Arch.  f.  Kinderheilkunde,  1902-1903,  xxxv,  S.  413. 
Poussin:    Observation  sur  l'expulsion  de  l'abdomen  par  une  ouverture  a  l'ombilic  de  plusieurs 

vers  ascarides-lombrico'ides.     Jour,  de  med.,  1817,  xl,  81. 
Richter,  H.  E.:    Bandwurmglieder  aus  einer  Bauchfistel  entleert.     Schmidt's  Jahrbuch,  1855, 

lxxxv,  308. 
Siebold :  Abgang  eines  Bandwurms  aus  dem  Nabel,  nebst  einigen  Bemerkungen  uber  das  Wandern 

der  Eingeweidewurmer.     Med.  Zeitung,  Berlin,  1843,  xii,  75. 
Stiles:  Hygienic  Laboratory,  U.  S.  Government,  Washington.     (Personal  communication.) 
Tillmanns,  H. :   Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring  (Ectopia 

Ventriculi)  und  liber  sonstige  Geschwulste  und  Fisteln  des  Nabels.     Deutsche  Zeitschr.  f. 

Chir.,  1882-83,  xviii,  161. 
Weiss,  E. :    Ueber  diverticular  Nabelhernien  und  die  aus  ihnen  hervorgehenden  Nabelfistelen . 

Inaug.  Diss.,  Giessen,  1868. 


CHAPTER  XXII. 

THE  ESCAPE   OF  VARIOUS   FOREIGN    SUBSTANCES  FROM  THE  UM- 
BILICUS. 

Gall-stones  escaping  at  the  umbilicus;   report  of  cases. 

Hydatids  at  the  umbilicus. 

The  escape  of  liquor  amnii  or  of  fetal  remains  through  the  umbilicus. 

Escape  of  foreign  bodies  through  the  umbilicus. 

GALL-STONES  ESCAPING  AT  THE  UMBILICUS. 

The  escape  of  gall-stones  from  the  umbilicus  is  very  rare.  One  of  the  earlier 
reported  cases  was  that  of  Buettner,  published  in  1744.  I  have  been  unable  to 
obtain  the  original  article,  but  it  was  referred  to  by  Duplay  in  1833.  In  Buettner's 
case  38  biliary  calculi  escaped  from  the  umbilicus.  Berard,  in  the  French  Dic- 
tionary of  Medicine,  published  in  1840,  says  that  there  were  several  examples  of 
a  biliary  fistula  opening  at  the  umbilicus,  and  sometimes  associated  with  the  escape 
of  calculi.  The  most  exhaustive  and  best  treatise  on  the  subject  is  that  of  Legue- 
linel  de  Lignerolles,  published  in  Paris  in  1869.  Other  names  closely  identified  with 
the  development  of  the  subject  are  Nicaise,  Murchison,  Courvoisier,  and  Ledder- 
hose.  According  to  Nicaise,  Murchison  collected  86  cases  in  which  the  gall-bladder 
opened  in  the  right  hypochondrium  on  a  level  with  the  fundus  of  this  viscus; 
in  other  cases,  in  regions  more  or  less  distant  in  the  abdominal  wall.  In  a  certain 
number  of  the  cases  they  opened  at  the  umbilicus.  Courvoisier,  in  his  Pathology 
and  Surgery  of  the  Bile-ducts,  published  in  1890,  gives  the  following  table  of  169 
cases  in  which  the  gall-bladder  opened  through  the  abdominal  wall : 

In  the  right  hypochondrium '. 49  times 

At  the  edge  of  ribs  on  the  right  side 36 

In  the  right  mesogastrium 17 

In  the  right  iliac  region 10 

In  the  epigastrium 6 

In  the  neighborhood  of  the  umbilicus 26 

Through  the  umbilicus 12 

Below  the  umbilicus . 11 

In  the  left  inguinal  region 1  time 

Multiple  openings 1      " 

From  this  table  it  will  be  noted  that  in  26  of  the  169  cases  the  opening  occurred 
in  the  neighborhood  of  the  umbilicus;  in  12  instances  at  the  umbilicus,  in  11  cases 
below  the  umbilicus.     Thus  in  49  cases  it  occurred  at  or  near  the  umbilicus. 

I  have  not  attempted  to  cover  the  literature  on  the  subject,  but  have  gathered 
together  only  sufficient  material  to  give  a  fairly  comprehensive  composite  picture 
of  this  class  of  cases.  Of  course,  this  complication  will  naturally  occur  during  the 
decades  when  gall-stones  are  most  frequently  found.  The  youngest  patient  was 
twenty-three  years  of  age.  The  great  majority  of  the  patients  were  over  forty 
years  of  age. 

23  337 


338  THE    UMBILICUS    AND    ITS    DISEASES. 

Of  12  cases  of  biliary  fistula  at  the  umbilicus  of  which  we  have  definite  records. 
1  was  in  a  man  and  11  were  in  women.  This  large  percentage  in  women  is  rather 
striking,  and  may  be  due  in  some  measure  to  the  weakened  condition  of  the  umbili- 
cus as  a  result  of  the  stretching  caused  by  pregnancy.  I  am  not  in  a  position  to 
prove  this  point,  however,  as  data  on  pregnancy  in  these  cases  are  not  available. 

These  patients,  as  a  rule,  give  the  usual  history  of  gall-stones.  Sometimes  the 
initial  pain  is  in  the  gall-bladder  region,  but  occasionally  it  is  first  noted  in  the  left 
hypochondrium,  and  after  a  time  shifts  to  the  right  side.  In  addition  to  the  hepatic 
colic  noted  there  are  sometimes  nausea,  vomiting,  and  diarrhea.  After  a  varying 
length  of  time  changes  may  be  noted  at  the  umbilicus.  In  Bramann's  case  fully 
two  years  elapsed  before  the  umbilicus  was  involved. 

Umbilical  Changes.  —  The  umbilical  region  usually  becomes  indu- 
rated, and  may  remain  so  for  several  weeks  or  months.  In  other  cases  it  rapidly 
shows  signs  of  reddening,  becomes  painful,  and  may  soon  open  spontaneously. 

In  Clement's  case  the  reddening  around  the  umbilicus  was  treated  as  an  eczema 
for  some  time;  finally  a  biliary  fistula  developed. 

In  Richet's  case,  reported  by  Leguelinel  de  Lignerolles,  a  small  tumor  presented 
at  the  umbilicus,  and  in  three  months  had  grown  to  the  size  of  an  adult's  fist  and 
opened  spontaneously. 

When  the  abscess  breaks,  there  is  an  immediate  discharge  of  pus,  sometimes,  but 
not  always,  fetid.  In  Leclerc's  case  it  contained  sandy  particles.  With  the  escape 
of  pus  small  biliary  calculi  may  be  discharged.  As  a  rule,  however,  several  days 
elapse  before  any  are  noted.  If  they  are  small,  their  exit  may  occasion  little  in- 
convenience, but  when  they  are  of  any  appreciable  size,  their  expulsion  is  accom- 
panied by  marked  abdominal  contractions  and  much  pain.  In  some  of  the  cases 
it  was  only  on  probing  the  fistulous  tract  that  calculi  were  detected  at  the  bottom. 
When  the  stone  is  large,  it  may  become  firmly  wedged  in  the  fistula,  and  can  then 
be  removed  only  by  dilating  the  channel  and  grasping  the  stone  with  forceps. 
With  the  escape  of  a  large  stone  bile  may  for  the  first  time  appear  at  the  umbilicus. 
In  other  instances  the  discharge  has  never  showed  even  occult  bile. 

The  subsequent  history  of  the  fistula  depends  on  the  contents  of  the  gall-bladder, 
If  the  gall-bladder  contains  small  stones,  these  escape  from  time  to  time,  the  fistula 
frequently  being  temporarily  sealed  over  in  the  meantime.  Where  only  one  large 
stone  has  been  present,  after  its  expulsion  the  sinus  usually  closes  permanently. 
In  short,  when  once  the  umbilical  fistula  has  formed,  it  rarely  closes  permanently 
until  the  gall-bladder  has  been  completely  emptied  of  its  stones.  Stones  may 
escape  at  intervals  for  years. 

The  majority  of  the  patients  regain  their  normal  health.  In  the  case  of  Mad- 
ame X,  reported  by  Leguelinel  de  Lignerolles,  the  patient  became  emaciated  and 
died.  At  autopsy  a  contracted  gall-bladder  was  found  which  contained  a  calculus, 
and  a  calculus  was  present  in  the  hepatic  duct.  In  Robert's  case,  cited  by  Nicaise, 
dilatation  of  the  fistulous  tract  was  followed  by  peritonitis  and  death.  In  Leroy 
des  Barres'  case  the  patient,  six  years  later,  died  of  cancer  of  the  stomach  and  liver. 

Murchison's  description  of  the  mode  in  which  biliary  fistulse  penetrate  the 
abdominal  wall  in  various  places  is  most  instructive  and  is  well  worth  a  thorough 
study. 

When  the  fistula  develops  at  the  umbilicus,  it  is  either  due  to  perforation  of  the 
gall-bladder  with  abscess  formation  and  later  perforation  of  the  umbilicus  by  the 


THE    ESCAPE    OF    FOREIGN    SUBSTANCES    FROM    THE    UMBILICUS.         339 

abscess;   or  the  enlarged  and  prolapsed  gall-bladder  may  become  adherent  to  the 
umbilicus  and  open. 

In  some  cases  the  gall-bladder  is  excessively  long.  In  a  case  I  saw  with  Dr- 
Franklin  B.  Smith  in  Frederick,  Md.,  the  greatly  enlarged  viscus  hung  over  the 
brim  of  the  pelvis  and  almost  touched  the  uterus.  The  gall-bladder  was  distended 
with  stones.  Such  a  gall-bladder  could  very  readily  have  become  adherent  to  the 
umbilicus.  A  reference  to  Bramann's  case  will  show  that  in  that  case  the  gall- 
bladder projected  downward  almost  to  the  symphysis.  It  had  become  adherent 
and  opened  at  the  umbilicus. 

Cases  of  Biliary  Fistula  at  the  Umbilicus  with  the  Escape  of  Gall-Stones. 

In  America  very  little  attention  has  been  paid  to  biliary  fistulse  at  the  umbilicus, 
and  the  literature  in  the  English  language,  apart  from  the  excellent  monograph  of 
Murchison,  is  so  meager  that  I  append  a  number  of  cases  sufficient  to  give  an  ade- 
quate view  of  the  subject.  Furthermore,  although  these  cases  have  been  rare  in 
the  past,  they  will  be  even  rarer  in  the  future  because  of  the  prompt  operative  meas- 
ures now  invariably  adopted,  when  acute  or  chronic  inflammations  of  the  gall- 
bladder exist. 

Case  1  .  —  A  Biliary  Tumor  Forming  Two  Small  Ab- 
scesses at  the  Umbilicus,  Followed  by  Fistula  and 
Escape  of  Three  Biliary  Calculi.  Healing.*  —  This  case 
was  reported  from  the  clinic  given  on  January  11th  at  La  Pitie,  by  Professor 
Richet.  The  patient  had  complained  of  abdominal  pain  for  seven  or  eight  months 
previously.  For  three  months  she  had  noted  a  small  tumor  at  the  umbilicus,  but 
had  never  suffered  from  hepatic  colic  and  gave  no  history  of  jaundice.  The  pain 
had  been  accompanied  by  alternating  diarrhea  and  constipation.  On  her  admission 
to  Richet's  service  in  December  the  patient  presented  a  tumor  situated  in  the  umbili- 
cal region.  It  was  the  size  of  an  adult's  fist.  It  diminished  a  little  as  a  result  of 
fomentations  and  poultices,  but  was  very  red  and  painful  on  pressure.  It  gradually 
lost  the  character  of  a  phlegmon.  After  eight  or  ten  days  it  began  to  increase  in 
size.  The  skin  became  thinner  and  broke,  and  there  was  an  escape  of  pus  and  frag- 
ments of  albumin  and  fibrin.  A  fistulous  opening  formed  a  few  days  later.  A 
probe  introduced  into  the  two  openings  disappeared  for  a  depth  of  7  cm.  and  im- 
pinged upon  a  hard  body.  The  patient  at  this  time  was  pale,  somewhat  jaundiced, 
and  had  lost  a  little  in  weight.  Richet  considered  in  the  differential  diagnosis  acute 
phlegmon,  abscess  of  the  glands,  cold  abscess,  cancer,  a  syphilitic  tumor,  fecal 
fistula,  and  a  fetal  cyst. 

On  February  10th  the  tumor  was  opened  and  a  large  quantity  of  pus  was  evacu- 
ated. The  two  orifices  were  opened  by  a  long  incision.  At  the  bottom  was  a  hard 
body  which  was  free,  mobile,  and  had  facets.  Richet  endeavored  to  remove  it 
with  forceps,  but  did  not  succeed.  A  few  clays  later  the  body  had  approached 
more  and  more  to  the  surface,  and  on  February  17th  a  biliary  calculus  escaped. 
Richet  probed  again  and  detected  a  second  calculus.  This  escaped.  A  few  clays 
later  a  third  calculus,  similar  to  the  two  others,  was  removed.  The  umbilical 
opening  closed  completely,  and  the  patient  was  discharged  well  in  the  early  part  of 
March. 

*  Leguelinel  de  Lignerolles:  Quelques  recherches  sur  la  region  de  l'ombilic  et  les  nstules 
hepatiques  ombilicales.     These  de  Paris,  1869,  No.  6,  obs.  1. 


340  THE    UMBILICUS    AND    ITS    DISEASES. 

Fistulous  Abscess  of  the  Liver  Communicating  with 
the  Gall-bladder;  Dilatation  and  Cauterization  of 
the  Fistulous  Tract;  Escape  of  14  Small  Faceted  Cal- 
culi and  of  Two  Large  Calculi  Without  Facets.*  —  In 
April  Dr.  Vacher  was  called  to  see  a  woman,  twenty-three  years  of  age,  who  had  a 
good  previous  history.  She  said  that  following  a  cut  she  had  had  an  abscess  of  the 
liver.  This  abscess  had  opened  spontaneously  and  for  two  months  there  had  been 
a  purulent  discharge  from  the  umbilicus,  with  pain  and  fever.  A  fistula  had  re- 
sulted. Vacher  found  a  fistulous  opening  about  three  fingerbreadths  from  the 
umbilicus.  On  pressure  seropurulent  fluid  escaped  from  it.  A  sound  penetrated 
transversely  and  to  the  right  for  a  depth  of  4  cm.  Abscess  of  the  liver  was  diag- 
nosed. Crepitation  was  transmitted  to  the  sound,  indicating  old  calcareous  con- 
cretions like  those  sometimes  found  in  the  bottom  of  a  cyst.  The  consultant 
advised  against  dilatation  of  the  fistula  and  gave  an  unfavorable  prognosis.  Vacher, 
however,  dilated  the  fistulous  tract  with  sponges,  and  then  could  detect  with  a 
sound  distinct  signs  of  a  calculus.  The  calculus  escaped  spontaneously  a  few  days 
later.  It  was  blackish,  faceted,  and  the  size  of  a  pea.  Greenish  bile  also  escaped 
with  the  calculus.  Two  and  later  four  other  calculi  of  the  same  size  came  away. 
A  calculus  of  large  dimensions  presented  and  was  removed  with  a  polyp  forceps. 
It  was  the  size  of  a  pigeon's  egg,  similar  to  the  others,  and  consisted  of  cholesterin. 
Three  or  four  days  later  a  similar  calculus  was  extracted  in  the  same  manner. 
From  this  moment  the  patient  improved.  The  tract  was  kept  dilated  for  fifteen 
days.     The  patient  recovered  rapidly,  and  six  years  after  was  in  excellent  health. 

A  Biliary  Tumor  Opening  Spontaneously  in  the 
Umbilical  Region,  with  Escape  of  a  Calculus  and  Devel- 
opment of  a  Fistula. f  — ■  In  the  first  part  of  February,  1862,  a  man,  aged 
forty-one,  came  saying  that  he  had  suffered  with  pain  at  the  umbilicus  for  some 
time.  At  the  umbilicus  was  a  reddish  tumor  the  size  of  a  walnut,  painful  on  pres- 
sure, and  fluctuating.  It  was  taken  for  an  abscess.  It  opened  spontaneously  the 
next  day,  and  a  calculus  with  a  small  quantity  of  seropurulent  liquid  escaped. 
The  cavity  occupied  by  the  calculus  was  lined  with  granulation  tissue.  On  the 
sixth  clay  it  presented  a  small  opening  from  which  a  little  serous  pus  escaped.  In 
the  course  of  eight  days  the  opening  was  completely  closed.  It,  however,  reestab- 
lished itself,  and  pus  escaped,  but  no  other  calculi.  In  May,  1868,  this  patient  had 
ascites  and  cachexia  and  died  in  October  from  cancer  of  the  liver  and  of  the  stomach. 

A  Cystic  Tumor  Opening  in  the  Region  of  the  Umbili- 
cus; Escape  of  Biliary  Calculi  From  the  Fistula.  J  — 
This  case  was  originally  reported  by  Dr.  John  Cockle. §  A  woman,  fifty-nine  years 
old  and  well  developed,  had  complained  of  very  severe  pain  in  the  abdomen  for  nine 
days  before  her  entrance  to  the  hospital.  She  had  had  nausea  and  vomiting. 
The  stools  had  been  normal,  and  there  had  been  no  jaundice.  At  the  level  of  the 
umbilical  region  there  was  a  tumor  which  was  red  and  inflamed,  and  there  was  also 
an  opening.     Eight  days  after  entrance  the  patient  discharged  14  small  calculi. 

*  Leguelinel  de  Lignerolles:  Op.  cit.,  obs.  2.  [Abstract  from  Traite  d'affections  calculeuses 
du  foie,  Fauconneau-Dufresne,  482.] 

t  Leguelinel  de  Lignerolles:  Op.  cit.,  obs.  3.  [Observation  by  Dr.  Leroy  des  Barres,  of 
Saint  Denis.     This  case  was  related  to  the  author  by  the  son  of  Dr.  Leroy.] 

X  Leguelinel  de  Lignerolles:   Op.  cit.,  obs.  4. 

§  Cockle,  John:  Med.  Times  and  Gaz.,  May  10,  1862,  p.  476. 


THE    ESCAPE    OF    FOREIGN    SUBSTANCES    FROM    THE    UMBILICUS.         341 

Several  days  later  three  more  calculi  came  away.  The  redness  then  disappeared, 
but  the  fistula  remained.  At  a  point  2  cm.  to  the  right  and  below  the  umbilicus 
was  a  seromucous  discharge.  A  probe  detected  the  presence  of  a  hard  calculus, 
which  appeared  to  be  the  size  of  a  hen's  egg.  There  was  also  an  increase  in  size  of 
the  liver.  After  some  time  the  swelling  and  redness  reappeared  and  another  cal- 
culus was  removed.  Three  weeks  later  still  another  became  fixed  in  the  fistulous 
tract,  about  2  cm.  from  the  opening.  As  a  result  of  the  disastrous  experience  which 
Robert  had  had  after  the  extraction  of  similar  calculi  under  like  circumstances,  the 
surgeon  did  not  attempt  to  remove  this  calculus,  but  from  time  to  time  small  biliary 
concretions  escaped. 

Tumor  of  the  Umbilical  Region;  Abscess  with  Fis- 
tulous Tract;  Spontaneous  Escape  of  Several  Bili- 
ary Calculi;  Grave  Jaundice;  Marked  Emaciation. 
Death.*  —  Madame  X,  aged  sixty-five,  had  suffered  from  chronic  gastritis. 
In  1857  she  complained  of  vague  pain  in  the  right  hypochondrium  and  a  tumor 
could  be  made  out  in  the  region  of  the  umbilicus.  The  tumor  was  hard,  without 
any  nodulation,  and  was  painful  on  pressure.  It  opened  at  the  umbilicus,  and  a 
considerable  quantity  of  whitish  pus  escaped.  In  March,  1858,  a  biliary  calculus 
appeared,  and  in  the  course  of  six  months  a  large  number  escaped  spontaneously. 
The  opening  closed  after  the  exit  of  each  calculus,  but  reopened  to  allow  another 
to  pass  out.  The  patient  gradually  became  emaciated,  and  died  with  a  marked 
jaundice.  At  autopsy  a  sound  introduced  at  the  umbilicus  passed  into  a  cul-de-sac 
3  cm.  in  depth.  The  liver  was  increased  in  size,  and  infiltrated  with  biliary  material. 
The  gall-bladder  was  transformed  into  a  small,  very  hard  tumor,  round,  the  size  of 
a  walnut.  It  contained  a  calculus  resembling  those  which  had  escaped.  The 
hepatic  duct  was  obstructed  by  a  calculus. 

Escape  of  a  Biliary  Calculus  by  an  Abscess  to  the 
Left  of  the  Umbilicus. f  —  This  case  was  reported  by  Alle.t  A 
woman,  forty-six  years  of  age,  had  had  good  health  until  1828,  when  she  had  had 
what  was  called  "nervous  fever"  (typhoid  ?).  In  1830  she  commenced  to  complain 
of  pain  in  the  left  hypochondrium.  A  tumor  was  detected.  The  patient  went  to 
take  the  waters  at  Baden,  but  on  her  way  there  had  very  severe  pain  in  the  right 
hypochondrium,  accompanied  by  headache  and  vomiting.  In  July,  1831,  the 
skin  in  the  region  of  the  umbilicus  became  inflamed.  After  applications  of  poultices 
an  abscess  developed,  which  opened  and  a  considerable  quantity  of  pus  escaped. 
On  October  24th  the  patient  experienced  a  very  unusual  sensation.  She  felt  as  if 
a  foreign  body  had  broken  in  the  cavity  of  the  abscess,  and  on  the  twenty-seventh 
noticed  something  hard  presenting  at  the  opening.  A  biliary  calculus  the  size  of  a 
pigeon's  egg  escaped.  The  general  condition  of  the  patient  was  grave.  She  was 
becoming  markedly  emaciated,  and  had  a  continuous  fever  with  exacerbations  in 
the  evenings  and  night-sweats.  She  was  also  constipated.  The  fistulous  tract  did 
not  have  the  dimensions  of  a  lentil.  A  probe  introduced  impinged  upon  a  hard, 
immovable  body.  The  opening  was  increased  in  size  with  a  sponge.  On  November 
25th  a  calculus  presented.     The  surgeon  attempted  to  remove  it  with  forceps,  but 

*  Leguelinel  de  Lignerolles:  Op.  cit.,  obs.  5.     Abstract  from  L'Union  med.,  1859,  465. 
t  Leguelinel  de  Lignerolles:  Op.  cit.,  obs.  6. 

t  Alle  (in  Briinn) :   Vier  grosse  Gallensteine,  welche  durch  einen  Abscess  zunachst  unter  dem 
Nabel  abgingen.     Med.  Jahrb.  K.  K.  Oster.  Staates,  1837,  N.  F.  xii,  115. 


342  THE    UMBILICUS   AND    ITS    DISEASES. 

it  broke  into  four  large  fragments  and  several  smaller  ones.  These  were  extracted, 
and  the  patient's  health  improved.  The  pain  was  severe,  but  the  fistulous  tract 
closed.  In  May,  1835,  the  fourth  calculus  was  removed.  Fifteen  days  later  the 
opening  closed  completely,  and  it  required  only  one  month  for  the  patient  to  regain 
her  general  health.  When  the  fragments  of  the  extracted  stone  were  assembled, 
it  was  found  that,  together,  they  formed  one  calculus. 

Biliary  Calculus  Escaping  From  the  Umbilical  Re- 
gion .  *  —  A  woman,  sixty-seven  years  of  age,  had  had  pain  in  the  epigastrium, 
in  the  right  hypochondriac  region,  and  in  the  umbilical  region.  At  the  umbilicus 
she  developed  a  tumor  which,  by  February,  1858,  had  reached  enormous  proportions. 
Her  general  condition,  however,  was  satisfactory.  At  the  beginning  of  April  the 
tumor  had  a  projection  in  its  center.  The  skin  at  this  point  was  thin  and  red.  On 
the  eighth  day  a  large  quantity  of  pus,  sandy  in  character  and  fetid,  escaped. 
Iodin  and  quinin  were  injected.  Shortly  afterward  the  patient  went  back  to  her 
work,  but  from  time  to  time  she  had  pain  at  the  umbilicus  and  a  seropurulent  dis- 
charge; a  fistula  remained.  Four  years  later  the  pain  returned.  In  January,  1861, 
a  blackish  liquid  with  foul  odor  escaped  from  the  fistula.  At  the  same  time  at  the 
orifice  of  the  fistula  was  seen  a  black  body,  which  escaped  on  Januarjr  23d,  after 
violent  abdominal  contractions  and  much  pain;  it  was  hard,  resistant,  and  the  size 
of  a  pigeon's  egg.  A  sound  introduced  into  the  opening  disappeared  for  a  distance 
of  5  cm.  without  impinging  upon  any  solid  body.  The  patient  recovered.  The 
body  expelled  without  doubt  was  a  biliary  calculus  which  had  made  a  channel 
toward  the  abdominal  wall  in  the  umbilical  region.  It  was  dark  green  in  color,  had 
the  appearance  and  consistence  of  cholesterin,  and  burned  in  the  flame  of  a  candle. 

A  Biliary  Tumor  Descending  Toward  the  Umbilicus; 
Escape  of  a  Calculus;  Fistula.  Recovery. f  —  The  wife  of  a 
pharmacist  had  been  gradually  weakened  as  a  result  of  long  suffering  from  hepatic 
colic.  Reaching  from  the  gall-bladder  region  toward  the  umbilicus  was  a  tumor 
evidently  containing  a  calculus  which  could  be  easily  felt.  This  tumor  ulcerated, 
bile  escaped,  and  also  a  biliary  calculus.  The  patient  felt  relieved  and  the  opening 
closed.  In  the  course  of  three  months  a  new  opening  occurred  in  the  region  of  the 
cicatrix  and  a  second  calculus  escaped.     It  had  evidently  lain  in  the  gall-bladder. 

Biliary  Fistula  at  the  Umbilicus.!  —  The  patient  in  Bra- 
mann's  Case  2  was  an  unmarried  woman,  sixty-three  years  of  age.  She  had  had 
typhoid  fever  at  thirteen.  At  forty-five  years  of  age  she  had  complained  of  a  sudden 
abdominal  pain,  had  had  a  high  fever,  much  discomfort  in  the  gall-bladder  region, 
and  some  nausea.  The  abdomen  was  somewhat  swollen.  A  tumor  the  size  of  a 
fist  had  been  made  out  in  the  umbilical  region  above  and  to  the  right.  It  had  grown 
slowly  and  tended  to  pass  more  and  more  downward  toward  the  symphysis. 

Two  years  later  a  large  quantity  of  foul-smelling  pus  had  escaped  from  the 
umbilicus.  This  discharge  had  continued,  the  amount  varying  at  different  times. 
The  patient  was  in  good  condition. 

On  admission  her  abdomen  was  slightly  distended.    The  skin  covering  the  umbili- 

*  Leguelinel  de  Lignerolles:  Op.  oit.,  obs.  7.  Abstract  from  a  case  reported  by  Dr.  Le- 
clerc,  Gaz.  des  hopitaux,  1863,  p.  48. 

t  Leguelinel  de  Lignerolles:  Op.  cit.,  obs.  8.  [This  case  was  observed  by  Dr.  Manec  and  re- 
ported by  Fauconneau-Dufresne.] 

t  Bramann,  F.:  Zwei  Falle  von  offenem  L'rachus  bei  Erwachsenen.  Arch.  f.  klin.  Chir., 
Berlin,  1887,  xxxvi,  996. 


THE    ESCAPE    OF    FOREIGN    SUBSTANCES    FROM    THE    UMBILICUS.         343 

cus  was  covered  with  crusts  and  exfoliated  epithelium  and  small  cysts.  The  umbili- 
cus was  retracted,  and  a  small  fistulous  tract  was  discharging  foul-smelling  pus. 

On  palpation  exactly  in  the  middle  line  a  long,  egg-shaped  tumor  could  be  felt. 
At  the  umbilicus  this  was  5  cm.  broad.  It  extended  almost  to  the  symphysis,  and 
its  lower  end  was  from  7  to  8  cm.  wide.  The  tumor  lay  distinctly  behind  the 
abdominal  wall,  and  only  in  the  neighborhood  of  the  umbilicus  was  it  intimately 
attached.  In  the  lower  part  it  was  somewhat  movable.  On  pressure  it  was 
found  to  be  of  dense  consistence.  A  sound  could  be  passed  12  cm.  toward  the 
symphysis,  and  the  cavity  widened  out  as  it  passed  downward.  Calculi  were  de- 
tected in  the  bottom  of  the  cavity.     The  urine  was  always  normal. 

Operation. — An  incision,  8  cm.  long,  was  made  from  the  umbilicus  downward. 
Four  faceted  calculi  the  size  of  pigeon's  eggs  were  removed  from  the  sac.  The 
cavity  was  cureted  out.  Healing  occurred  after  three  months,  but  it  was  necessary 
to  curet  several  times.  Microscopic  examination  of  the  calculi  yielded  choles- 
terin  and  bile-pigment,  but  no  urinary  salts. 

Fatal  Peritonitis  Following  a  Biliary  Fistula  at 
the  Umbilicus.*  —  A  woman,  thirty-five  years  of  age,  had  had  for  eight 
months  a  purulent  fistula  at  the  umbilicus.  With  a  catheter  introduced  into  the 
fistula  Robert  was  able  to  detect  a  calculus  situated  at  the  bottom  of  the  traet. 
He  dilated  the  tract,  but  the  patient  developed  peritonitis  and  died. 

Escape  of  Biliary  Calculi  From  the  Umbilicus.  — 
Clementj  showed  at  the  Medical  Society  two  biliary  calculi.  The  woman  had  had 
previous  attacks  of  abdominal  pain.  When  seen  by  Clement,  she  had  a  reddening 
around  the  umbilicus.  This  was  unsuccessfully  treated  as  an  eczema.  A  fistula 
developed,  and  two  days  later  a  calculus  escaped.  On  the  day  previous  to  the 
meeting  Clement  had  extracted  the  two  very  small  calculi  from  the  umbilicus. 

A  Biliary  Fistula  at  the  Umbilicus.  —  Poncett  saw  a  patient 
with  an  umbilical  fistula  which  from  time  to  time  discharged  bile.  The  physician, 
under  whose  care  the  patient  was,  said  that  in  the  beginning  an  abscess  had  de- 
veloped and  a  calculus  had  escaped.    The  resultant  fistula  resisted  all  treatment. 

*  Robert:  Cited  by  Nicaise:  Ombilic.  Dictionnaire  encyclopedique  des  sc.  med.,  Paris, 
1881,  2.  ser.,  xv,  140. 

t  Clement:  Lyon  med.,  1888,  lvii,  53.  i  Poncet:  Lyon  med.,  188S,  lvii,  54. 

LITERATURE  CONSULTED  ON  GALL-STONES  ESCAPING  FROM  THE  UMBILICUS. 

Berard,  P.  H. :   Diet,  de  med.,  Paris,  1840,  xxii,  66. 

Bramann,  F.:  Zwei  Falle  von  offenem  Urachus  bei  Erwachsenen.  Arch.  f.  klin.  Chir.,  Berlin, 
1887,  xxxvi,  996. 

Clement:   Lyon  med.,  1888,  lvii,  53. 

Courvoisier,  L.  G. :  Casuistisch-statistische  Beitrage  zur  Pathologie  und  Chirurgie  der  Gallenwege, 
Leipzig,  1890,  117. 

Duplay:  Arch.  gen.  de  med.,  1833,  2e  serie,  i,  373. 

Ledderhose,  G. :   Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  bs 

Leguelinel  de  Lignerolles:  Quelques  recherches  sur  la  region  de  l'ombilic  et  les  fistules  hepatique. 
ombilicales.     These  de  Paris,  1869,  Xo.  6. 

Alurchison,  C. :  Case  of  communication  with  the  stomach  through  the  abdominal  parietes  pro- 
duced by  ulceration  from  external  pressure.     Medico-chir.  Trans.,  London,  1858,  xli,  p.  11. 

Nicaise:  Ombilic.  Dictionnaire  encyclopedique  des  sciences  medicales,  Paris,  1881,  2.  ser.,  xv, 
140. 

Poncet:   Lyon  medical,  1888,  lvii,  54. 


344  THE    UMBILICUS    AND    ITS    DISEASES. 

HYDATIDS  AT  THE  UMBILICUS. 

The  presence  of  hydatids  at  the  umbilicus  is  exceptional.  Examples  have,  how- 
ever, been  recorded  by  Guattani,  Dupuytren,  Thompson,  Berard,  and  Roux. 

The  parent  echinococcus  cyst  usually  develops  in  the  liver,  and  the  growth 
gradually  extends  to  the  umbilical  region.  The  tumors  may  become  adherent  to 
the  umbilicus  and  open,  fluid  and  daughter-cysts  escaping.  Dupuytren's  case  is 
particularly  interesting,  in  that  autopsy  showed  that  the  primary  focus  was  in 
the  lung.  The  fistulous  tract  had  perforated  the  diaphragm;  it  lay  between  the 
liver  and  abdominal  wall,  and  opened  at  the  umbilicus. 

Leguelinel  de  Lignerolles  reported  Guattani's  case.*  The  patient  was  a  man, 
forty-eight  years  of  age,  who  had  had,  in  the  region  of  the  liver,  a  tumor  which  was 
resistant,  circumscribed,  and  tense.  In  the  center  an  obscure  fluctuation  could  be 
detected.  Guattani  was  uncertain  as  to  its  character,  and  decided  to  temporize. 
Nine  months  later  the  tumor  was  prominent,  the  skin  had  become  reddened,  and 
through  an  opening  at  the  umbilicus  there  escaped  more  than  300  hydatid  cysts. 
A  stilet  introduced  into  the  fistulous  tract  detected  a  large  cavity  which  it  was 
impossible  to  explore  thoroughly.  The  fistulous  tract  remained  open  for  a  long 
time  without  any  inconvenience  to  the  patient.  Healing  took  place  six  years  after- 
ward. [I  was  not  able  to  study  this  case  in  the  original.  There  seems  to  be  some 
controversy,  however,  as  Nicaise  says  the  observation  of  Guattani  cannot  be  con- 
sidered as  an  example  of  hydatid  fistula  at  the  umbilicus.  He  claims  that  the  tumor 
was  in  reality  in  the  epigastric  and  not  in  the  umbilical  region,  and  that  it  ruptured, 
with  the  escape  of  more  than  300  hydatids.] 

Dupuytren  reported  his  case  in  1833.  A  woman  entered  the  Hotel-Dieu  in 
1811  with  an  inflammatory  tumor  of  the  umbilicus.  As  fluctuation  was  evident, 
and  as  it  was  manifest  that  the  skin  would  give  way,  Dupuytren  opened  it  and  a 
large  quantity  of  pus  escaped,  and  with  it  several  hydatid  cysts.  The  woman  died. 
At  autopsy  a  communication  was  found  between  the  umbilical  opening  and  a  cavity 
in  the  lung.  The  fistulous  tract  had  perforated  the  diaphragm  and  lay  between 
the  liver  and  the  abdominal  wall.  The  cavity  in  the  lung  contained  a  large  number 
of  hydatid  cysts.     It  was  evident  that  the  lung  was  the  primary  seat  of  the  hydatids. 

Leguelinel  de  Lignerolles  cites  Thompson's  case.  The  original  appeared  in  the 
Medical  Gazette,  1844,  and  was  recorded  in  the  Memoirs  of  the  Medical  Society, 
London.  The  patient  at  intervals  for  a  period  of  thirty  years  had  discharged 
hydatid  cysts  from  the  umbilicus.  She  died  at  the  age  of  fifty-three.  The  swell- 
ing was  first  noted  after  an  abdominal  injury.  Following  an  abdominal  incision 
she  discharged  numerous  cysts,  accompanied  by  a  peculiar  liquid  which  was 
sometimes  purulent.  The  cysts  continued  to  escape  through  an  opening  which 
developed  at  the  umbilicus,  and  the  patient  experienced  a  great  deal  of  abdominal 
pain.  She  had  frequent  attacks  of  diarrhea  and  occasionally  fell  into  a  state  of 
great  weakness.  At  autopsy,  at  the  umbilicus  were  found  two  tumors  communicat- 
ing with  the  opening.  The  one  contained  friable  material  mixed  with  "quicklime," 
the  other  had  very  fetid  contents.  The  fistula  passed  to  the  upper  portion  of  the 
liver,  with  which  it  had  evidently  communicated.  Eight  or  nine  isolated  hydatid 
cysts  were  found  on  the  surface  of  the  liver,  and  there  was  also  an  abscess  which 
contained  pus  and  remnants  of  hydatids.     The  gall-bladder  was  very  much  dis- 

*  Guattani:  De  ext.  Aneurys.,  Roma,  1772,  109. 


THE    ESCAPE    OF    FOREIGN    SUBSTANCES    FROM    THE    UMBILICUS.        345 

tended  and  contained  similar  cysts.  In  addition  there  were  numerous  hydatids 
between  the  folds  of  the  mesentery. 

Berard,  in  1840,  reported  the  case  of  a  woman  who  entered  his  service  at  St. 
Anthony's  Hospital.  For  eighteen  months  she  had  had  an  umbilical  fistula.  On 
pressure  over  the  right  hypochondrium  the  purulent  discharge  from  the  umbilicus 
increased,  and  with  the  pus  escaped  several  empty  hydatid  sacs. 

Nicaise  refers  to  Roux's  case,  which  had  been  reported  by  Cruveilhier.  A 
woman  had  at  the  umbilicus  a  tumor  which  had  been  taken  for  a  hernia  and  a  ban- 
dage had  been  applied.  Roux  noted  that  the  skin  covering  the  tumor  had  spon- 
taneously opened;  that  there  was  a  convex  surface,  whitish  and  prominent,  at  the 
opening  of  the  skin.  He  thought  of  a  hernial  sac.  He  made  several  incisions  to 
relieve  the  supposed  strangulation,  and  was  surprised  to  find  that  he  was  dealing 
with  hydatid  cysts. 

Fischer,  in  his  article  on  Suppurations  in  the  Subumbilical  Space,  drew  attention 
to  an  isolated  echinococcus  cyst  of  the  abdominal  wall.  This  was  not  situated  at 
the  umbilicus,  but  immediately  in  its  vicinity,  and  was  in  no  way  connected  with 
the  abdominal  cavity.  It  is  of  such  interest  that  I  report  it  in  detail.  He  says 
(p.  537)  that  he  operated  on  a  man  thirty-two  years  of  age  in  whom  a  painless, 
smooth,  fluctuating,  immovable  tumor,  the  size  of  a  fist,  had  developed  beneath 
and  to  the  right  of  the  umbilicus  near  the  mid-line.  Its  increase  in  size  had  been 
very  gradual,  as  it  took  six  years  for  development.  The  patient  during  this  time 
had  often  had  vomiting,  but  was  otherwise  healthy.  For  three  weeks  the  tumor 
had  been  painful  and  increasing  in  size.  The  skin  had  become  reddened  and  ede- 
matous. The  tumor  had  the  size,  form,  and  position  of  the  subumbilical  space. 
Fischer  made  an  incision  in  the  outer  wall  of  the  rectus  along  the  subumbilical 
space,  and  found  a  densely  adherent  echinococcus  sac,  which  could  not  be  extir- 
pated on  account  of  its  firm  adherence  to  the  peritoneum.  He  split  it,  scraped  it 
out,  and  packed.     The  patient  recovered  and  apparently  remained  well. 


LITERATURE  CONSULTED  ON  HYDATIDS  AT  THE  UMBILICUS. 
Berard,  P.  H. :  Diet,  de  med.,  Paris,  1840,  xxii,  66. 
Davaine,  C. :   Traite  des  entozoaires,  Paris,  1860,  416. 
Dupuytren:  Tumeurs  hydatiques.     Clin,  chir.,  1833,  iii,  378. 
Fischer:   Die  Eiterungen  im  subumbilicalen  Raume.     Volkmann's  Samml.  klin.  Vortrage,  n.F., 

No.  89  (Chirurg.  No.  24),  Leipzig,  1890-94,  519. 
Ledderhose,  G.:   Chirurg.  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Leguelinel  de  Lignerolles:   Quelques  recherches  sur  la  region  de  l'ombilic  et  les  fistules  hepatiques 

ombilicales.     These  de  Paris,  1869,  No.  6. 
Nicaise:    Ombilic.     Dictionnaire  encyclopedique  des  sc.  med.,  Paris,  1881,  2.  ser.,  xv,  140. 

THE  ESCAPE  OF  LIQUOR  AMNII  OR  OF  FETAL  REMAINS  THROUGH  THE  UMBILICUS. 
A  tubal  pregnancy  of  small  size  niay  in  time  almost  totally  disappear.  If  it 
be  of  moderate  dimensions  and  not  operated  upon,  it  may  remain  in  situ,  nothing 
but  the  distorted  skeleton  being  left.  I  saw  a  most  interesting  example  of  this 
condition  about  fifteen  years  ago.  Dr.  J.  Whitridge  Williams  received  the  specimen 
from  New  York,  and  on  making  a  careful  examination  found  that  the  tube  near  the 
uterus  contained  a  recent  small  pregnancy,  while  in  the  outer  end  of  the  same  tube 
was  the  skeleton  of  a  previous  tubal  pregnancy.     The  bones  of  this  fetus  had  been 


346  THE    UMBILICUS    AND    ITS    DISEASES. 

compressed  into  a  rounded  mass  several  centimeters  in  diameter.  On  May  4, 
1907,  at  the  Johns  Hopkins  Hospital,  I  operated  on  a  colored  woman  (Gyn.  No. 
13806)  who  had  a  definite  mass  in  the  ileocecal  region.  Her  previous  history  was 
not  clear  and  did  not  give  us  a  clue  as  to  the  exact  condition.  On  making  an  inci- 
sion over  the  mass  I  found  a  packet  of  bones.  (See  Fig.  249,  p.  584.)  These  were 
gradually  dislodged.  The  end  of  one  femur,  which  was  fully  5  cm.  long,  had  pro- 
jected into  the  bladder,  and  the  portion  of  the  bone  that  had  come  in  contact  with 
the  urine  had  a  phosphatic  covering  several  millimeters  thick.  The  lumen  of  the 
large  bowel  in  the  vicinity  of  this  collection  of  bones  was  perforated  at  two  points, 
the  ends  projecting  into  the  intestinal  lumen.  The  opening  in  the  bladder  and  the 
apertures  in  the  bowel  were  closed  and  the  sac  drained.  The  patient  made  a 
prompt  recovery. 

In  the  case  reported  by  Pfeffinger  and  Fritze,  and  referred  to  by  Kussmaul, 
after  the  fetal  bones  had  remained  quiescent  in  a  rudimentary  uterine  horn  for  over 
thirty  years,  suppuration  had  developed  and  the  patient  died.  The  accuracy  of 
this  case  was  fully  attested,  as  the  patient  was  a  life  prisoner  and  had  escaped  capital 
punishment  years  before  only  because  at  the  time  of  the  trial  she  claimed  that  she 
was  pregnant.  This  case  Dr.  George  L.  Wilkins  and  I  referred  to  several  years 
ago. 

The  passage  of  fetal  bones  by  the  rectum  has  in  the  past  been  no  great  rarity. 
Where  the  pregnancy  has  been  abdominal,  the  fetus  in  many  instances  goes  on  to 
term  and  becomes  encapsulated,  as  was  well  seen  in  a  full-term  pregnancy  that  I 
removed  several  years  ago  and  where  the  child  had  lain  in  the  abdomen  for  four 
years.  Sometimes  the  child  may  become  calcified,  as  was  clearly  evident  in  the  case 
reported  by  Dr.  John  G.  Clark. 

In  the  foregoing  I  have  briefly  outlined  some  of  the  end-results  of  an  extra- 
uterine pregnancy.  While  going  over  the  literature  I  found  two  cases  in  which 
there  had  been  a  tendency  for  the  fetus  to  break  through  at  or  near  the  umbilicus, 
and  to  this  I  will  add  one  coming  under  my  own  care. 

Josenhans,  in  1841,  reported  the  case  of  a  woman,  sixty  years  of  age,  who  was 
married  at  twenty  and  in  short  succession  had  two  children.  At  thirty  she  com- 
plained of  severe  abdominal  pain,  with  a  rupture  near  the  umbilicus.  At  first  there 
was  an  escape  of  pus  and  then  fecal  matter,  and  on  several  occasions  pieces  of  bone 
and  hair.  The  fistula  remained  open  and  there  was  a  prolapsus  of  the  bowel 
through  the  opening.  The  patient  died  at  sixty-four.  There  had  evidently  been 
an  abdominal  pregnancy,  with  escape  of  parts  of  the  fetus  through  the  abdominal 
wall.  Had  the  bone  and  hair  been  due  to  a  dermoid,  a  suppurating  sinus  would 
always  have  remained. 

In  1874  Duboue  reported  the  case  of  a  woman,  aged  twenty-six,  who  entered 
the  maternity  hospital  after  being  in  labor  for  twenty-four  hours.  The  pain 
diminished,  and  the  patient  complained  of  nausea  and  vomiting.  On  examination 
the  enlargement  suggested  a  seven  and  one-half  months'  pregnancy.  The  tumor 
was  situated  more  to  the  right  than  to  the  left,  and  the  nurse  had  previously  made 
out  the  fetal  heart.  The  patient  improved  and  was  sent  home  to  await  results. 
In  February,  at  the  time  of  the  patient's  admission,  she  was  in  fairly  good  health. 
A  week  after  the  labor  pains  had  ceased,  the  patient  lost  her  appetite,  could  not 
sleep,  grew  thinner,  and  had  a  peculiar  brownish  tint  in  her  face.  On  February 
7th  she  noted  a  considerable  discharge  of  chocolate-colored  material  by  the  bowel. 


THE  ESCAPE  OF  FOREIGN  SUBSTANCES  FROM  THE  UMBILICUS.    347 

On  March  12th  she  again  entered  the  hospital.  The  uterus  was  dilated  on  March 
27th,  and  to  the  surprise  of  the  surgeon  was  found  to  be  empty.  On  April  9th  the 
sac  opened  at  the  umbilicus  and  the  fetus  was  then  extracted  piecemeal.  The  general 
peritoneal  cavity  was  not  opened,  but  the  cavity  containing  the  fetus  was  washed 
out.  Two  days  later  fecal  matter  came  out  of  the  sac.  The  patient  gradually 
improved,  and  was  discharged  on  June  6th.  The  fistula,  which  persisted  until 
September  of  the  same  year,  was  scarcely  perceptible,  but  there  was  an  occasional 
escape  of  gas. 

In  1901  I  saw  the  following  case  at  the  Cambridge  (Md.)  Hospital:* 
On  February  28,  1901,  Dr.  Goldsborough  was  called  in  by  Dr.  I.  N.  Tannar,  of 
Vienna,  Maryland,  to  see  what  the  doctor  supposed  to  be  a  case  of  obscure  preg- 
nancy. The  patient  had  had  one  child  nine  years  before.  In  April,  1900,  she  had 
missed  her  period  and  since  then  had  presented  the  usual  signs  of  pregnancy — 
nausea,  enlarged  breasts,  increase  in  size  of  the  abdominal  girth.  In  August,  while 
lifting  some  boxes,  something  had  suddenly  given  way  in  her  left  side.  This  had 
occasioned  severe  pain  and  she  had  remained  in  bed  until  November  1st.  About 
the  middle  of  September  there  had  been  a  bloody  uterine  discharge,  and  accom- 
panying it  considerable  pain  and  nausea.  Subsequently,  she  had  had  several 
similar  discharges,  which  may  have  been  menstrual  periods.  During  the  month 
of  November  she  had  been  able  to  be  out  of  bed,  but  had  had  to  return  in  December. 
Throughout  the  entire  illness  she  had  had  a  good  appetite  and  had  been  fairly  well 
nourished.  When  seen,  her  temperature  was  101.5°  F.;  her  pulse,  140.  Immediate 
removal  to  the  Cambridge  Hospital  was  advised,  and  on  the  following  day  she  was 
driven  23  miles. 

On  examination  under  anesthesia  the  abdomen  was  seen  to  be  very  prominent. 
There  was,  however,  no  bulging  in  the  flanks.  The  umbilicus  had  been  converted 
into  a  tumor  fully  5  cm.  long  by  3  cm.  broad  (Fig.  166).  The  skin  over  it  appeared 
to  be  much  thinned  out,  and  at  one  point  had  given  way.  From  this  abraded  area 
an  exceedingly  offensive,  chocolate-colored  fluid  was  escaping.  Around  the  umbili- 
cus the  tissue  was  markedly  indurated  and  pitted  on  pressure.  On  vaginal  exami- 
nation the  cervix  was  found  intact,  but  it  was  impossible  to  outline  the  uterus. 
Nothing  could  be  detected  laterally.  An  incision  was  made  just  below  the  sternum, 
and  continued  down  almost  to  the  pubes.  The  abdominal  cavity  proper  was  not 
exposed;  that  is  to  say,  none  of  the  abdominal  contents  came  into  view.  Filling 
the  cavity  was  a  large  quantity  of  chocolate-colored  fluid,  a  fetus  between  six  and 
seven  months,  and  a  large  placenta.  The  placenta  was  attached  low  down  in  the 
pelvis,  was  exceedingly  friable,  but  came  away  without  producing  any  hemorrhage. 
The  walls  of  the  sac  were  about  4  mm.  in  thickness  and  excessively  friable.  They 
reminded  me  very  much  of  granulation  tissue.  It  was  impossible  to  determine 
where  the  pregnancy  had  taken  place,  as  the  pelvic  organs  were  entirely  walled  off. 
It  is  probable,  however,  that  the  uterus  had  ruptured  and  that  the  fetus  with  its 
membranes  intact  had  escaped  into  the  abdominal  cavity.  The  fetal  membranes 
had  then  become  attached  to  the  abdominal  wall  and  to  the  surrounding  struc- 
tures. After  removal  of  the  fetus  and  the  placenta,  this  large  sac,  which  extended 
almost  from  the  sternum  to  the  pubes  and  laterally  filled  the  entire  anterior  portion 
of  the  abdomen,  was  thoroughly  washed  out  with  salt  solution  and  loosely  packed 

*  Goldsborough,  Brice  W.,  and  Cullen,  Thomas  S.:    A  Rare  Form  of  Extra-uterine  Preg- 
nancy.   Amer.  Medicine,  April  6,  1901,  p.  32. 


348 


THE    UMBILICUS    AND    ITS    DISEASES. 


with  iodoform  gauze.  The  upper  half  of  the  incision  was  closed,  the  lower  half  I  left 
open  to  insure  thorough  drainage.  At  the  time  of  operation  the  patient's  pulse  was 
140.     The  operation  occasioned  no  shock. 

After  the  operation  the  temperature  ranged  from  normal  to  101.5°  F.  for  the 
first  four  days,  but  after  that  time  became  normal.  The  pulse  was  weak  and  irreg- 
ular for  six  days,  but  gradually  regained  its  normal  tone.  The  pack  was  removed 
on  the  seventh  day,  with  the  escape  of  a  moderate  amount  of  discharge.  A  light 
gauze  drain  was  then  inserted.     On  March  13th  the  abdomen  was  perfectly  flat 


Fig.  166. — Abdominal  Pregnancy  with  Spontaneous  Escape  of  Liquor  Amnti  from  the  Umbilicus. 

The  drawing,  of  course,  is  somewhat  diagrammatic.  It  represents  a  longitudinal  section  of  the  body.  The 
fetus  and  the  fetal  membranes  are  lying  immediately  beneath  the  abdominal  wall,  and  are  attached  anteriorly  to 
the  peritoneum  almost  from  the  sternum  to  the  pubes.  At  the  umbilicus  the  fetal  sac  bulges  into  the  hernial  opening, 
and  at  the  most  prominent  point  this  hernial  sac  has  given  way,  allowing  the  fluid  to  escape  externally.  The  fetus 
is  well  preserved,  appears  to  be  about  six  months  old,  and  shows  slight  maceration  on  the  face,  arms,  and  legs.  The 
site  of  the  placenta  is  roughly  outlined  by  the  dotted  lines.  The  cervix  is  normal,  but  on  account  of  the  marked 
distortion,  the  presence  of  the  abdominal  tumor,  and  the  edema  it  was  impossible  to  outline  the  uterus  or  ap- 
pendages; hence  their  relation  is  left  hazy.  The  bladder  and  rectum  are  in  their  normal  positions.  As  will  be  seen 
from  the  drawing,  a  median  incision  in  the  abdominal  wall  would  open  directly  into  the  sac  and  in  no  way  involve  the 
general  peritoneal  cavity. 


and  all  evidence  of  edema  had  disappeared.  On  removal  of  the  drain  there  was  a 
slight  discharge.  On  bimanual  examination  it  was  now  possible  to  outline  the  uterus 
to  some  extent.  The  organ  was  about  the  size  of  a  two  months'  pregnancy,  and 
situated  directly  behind  the  pubes.     It  was  slightly  movable. 

Pathological  Report  (Gyn.  Path.  No.  4744). — The  specimen  consists  of  a  fetus 
with  its  accompanying  placenta.  The  fetus,  when  folded  upon  itself,  is  17  cm.  in 
length.  The  distance  from  the  occiput  to  the  heel  is  29  cm.  The  child  is  well 
formed,  shows  no  external  abnormality,  and  is  a  female.  There  is  a  moderate 
quantity  of  hair,  but  the  skin  has  to  a  great  extent  macerated,  and  the  pigmented 


THE    ESCAPE    OF    FOREIGN    SUBSTANCES    FROM    THE    UMBILICUS.         349 

layer  is  readily  peeled  off.  The  umbilical  cord  appears  to  be  about  8  cm.  in  length. 
It  shows  nothing  of  interest.  The  placenta  is  approximately  16  by  10  by  5  cm. 
It  is  very  friable.  In  some  places  it  presents  the  usual  appearance;  in  others, 
especially  in  the  depth,  the  tissue  is  somewhat  homogeneous,  hemorrhagic,  and 
seems  to  be  breaking  down. 

Histologic  examination  of  sections  from  various  parts  of  the  placenta  shows  that 
it  consists  almost  entirely  of  necrotic  tissue  and  canalized  fibrin.  The  contours  of 
the  villi  are  everywhere  visible,  but  the  nuclei  of  the  epithelial  cells,  as  well  as  those 
of  the  stroma  of  the  villi,  have  entirely  disappeared.  The  central  portions  of  nu- 
merous villi  are  partially  filled  with  calcareous  plaques.  At  one  point  are  a  mod- 
erate number  of  disintegrated  polymorphonuclear  leukocytes.  Otherwise  the 
entire  tissue  is  devoid  of  nuclei. 

This  complete  necrosis  of  the  placenta  accounts  for  the  ease  with  which  it  was 
peeled  off  and  also  for  the  absence  of  hemorrhage  during  its  removal. 

The  discharge  of  bone  and  hair  from  the  umbilicus,  although  it  affords  strong 
presumptive  evidence  of  pregnancy,  is  not  necessarily  conclusive,  as  shown  by  San- 
derson's case.  Dr.  S.  E.  Sanderson,  in  writing  me  from  Detroit  under  date  of  March 
31,  1913,  says:  "In  September,  1897,  I  was  called  to  see  a  German  woman  of  the 
poorer  class,  aged  about  twenty-seven,  married,  with  no  children.  She  was  suffer- 
ing from  a  large  abdominal  tumor,  and  at  the  same  time  there  was  a  bulging  at 
the  umbilicus  covered  with  reddened  skin  and  very  compressible.  This  swelling 
evidently  contained  fluid. 

"Several  days  after  seeing  this  patient  I  was  hurriedly  called  to  her  house.  On 
arriving  I  found  that  rupture  had  taken  place  through  the  umbilicus.  Several  pints 
of  a  pea-soup-like  fluid  and  two  or  three  teeth  had  been  discharged,  while  from  the 
opening  there  extended  a  long  strand  of  hair.  The  abdomen  was  greatly  diminished 
in  size,  and  the  patient  felt  more  comfortable.  I  advised  her  removal  to  the  hos- 
pital for  proper  care,  but  she  refused,  and  I  lost  track  of  her.  About  a  year  later 
I  was  told  that  she  had  gone  to  the  hospital  for  operation  and  had  had  a  large 
tumor  removed." 

As  Sanderson  says,  this  was  without  doubt  a  dermoid  cyst.  We  all  know  that 
dermoid  cysts  show  a  peculiar  tendency  to  become  adherent,  and  that  they  are 
prone  to  suppurate.  This  cyst  had  suppurated,  grown  fast  to  the  umbilicus,  and 
part  of  its  contents  had  escaped  through  the  umbilical  opening. 

LITERATURE  CONSULTED  ON  ESCAPE  OF  LIQUOR  AMNII  OR  FETAL  REMAINS 

THROUGH  THE  UMBILICUS. 

Clark,  J.  G. :  A  Rare  Case  of  Lithopedion.  Johns  Hopkins  Hosp.  Bull.,  November,  1897,  viii,  221. 
Cullen  and  Wilkins:    Pregnancy  in  a  Rudimentary  Horn,  Rupture,  Death,  Probably  Migration 

of  Ovum  and  Spermatozoa.     Johns  Hopkins  Hosp.  Reports,  1897,  vi,  126. 
Cullen,  T.  S.:    A  Series  of  Interesting  Gynecologic  and  Obstetric  Cases.     Jour.  Amer.  Med. 

Assoc,  May  4,  1907,  1491. 
Duboue:    Observation  de  grossesse  extra-uterine,  gastrotomie,  guerison.     Fistule  intestinale  au 

niveau  de  1'ombilic.     Arch,  de  tocologie,  des  maladies  des  femmes  et  des  enfants  nouveau- 

nes,  1874,  i,  577. 
Goldsborough  and  Cullen:   A  Rare  Form  of  Extra-uterine  Pregnancy.     Amer.  Medicine,  April  6, 

1901,  32. 
Josenhans:    Merkwurdiger  Fall  von  kiinstlichem  After.     Med.  Correspondenzbl.,  Wurtemberg, 

1841,  xi,  60. 


350  THE    UMBILICUS    AND    ITS    DISEASES. 

ESCAPE  OF  FOREIGN  BODIES  THROUGH  THE  UMBILICUS. 

Blum,  in  his  article  on  Tumors  of  the  Umbilicus  in  the  Adult,  published  in  1876, 
cites  three  cases — those  observed  by  Ambroise  Pare,  Diemerbroeek,  and  Greenhill. 

Ambroise  Pare's  patient,  a  woman,  had  swallowed  a  brass  needle.     Two  years  . 
later  it  passed  out  at  the  umbilicus  through  a  small  opening. 

Diemerbroeck's  patient,  a  child,  had  swallowed  a  shoemaker's  awl.  Later  a 
small,  painful,  non-suppurating  tumor  presented  at  the  umbilicus.  This  contained 
the  foreign  body. 

GreenhilTs  case  was  reported  in  the  Philosophical  Transactions  of  the  Royal 
Society  of  London  in  1700,  vol.  hi,  p.  93.  A  woman,  who  had  swallowed  a  certain 
number  of  plum-stones,  finally  developed  a  tumor  in  the  umbilical  region.  This 
suppurated,  and  the  stones  escaped  from  the  umbilicus.  The  woman  died  twenty 
days  later. 

"Weiss  briefly  referred  to  a  case  seen  by  Cladus.  The  patient  was  a  man. 
Plum-stones  and  worms  escaped  from  his  umbilicus. 

Petrequin's  case,  in  which  a  uterine  sound  introduced  through  the  vagina  was 
lost  and  finally  presented  at  the  umbilicus,  is  of  such  interest  that  I  shall  report  it  in 
detail. 

Uterine  Sound  Introduced  Into  the  Uterine  Cavity 
and  Removed  Through  the  Umbilicus.*  —  Madame  X,  mother  of 
several  children,  claimed  that  when  she  was  between  six  and  eight  weeks  pregnant 
a  midwife  had  introduced  a  sound  to  bring  on  a  miscarriage.  The  sound  was  passed 
far  up  and  could  not  be  reached  again.  Miscarriage  followed,  but  no  sound  came 
away.  Six  days  later,  after  the  most  careful  examination,  no  evidence  of  the 
sound  could  be  found.  Examinations  on  several  days  in  succession  were  of  no  avail. 
Four  months  later  the  patient  was  in  good  health,  but  came  to  the  hospital  on 
account  of  a  small  enlargement  at  the  umbilicus.  It  looked  like  a  beginning  umbili- 
cal hernia. 

On  bimanual  examination  with  the  patient  standing,  the  upper  end  of  the 
sound  could  be  felt  at  the  umbilicus.  The  uterus  was  dilated,  and  several  attempts 
made  to  remove  the  sound  from  below,  but  without  avail.  An  incision  was  finally 
made  at  the  umbilicus,  and  by  manipulation  the  sound  was  removed  from  above. 
The  patient  was  perfectly  well  in  seven  days.  In  this  case  the  sound  had  perforated 
obliquely  the  anterior  portion  of  the  cervix,  and  its  lower  end  had  slipped  between 
the  bladder  and  the  cervix,  while  the  upper  end  gradually  had  reached  the  umbili- 
cus.    Petrequin  and  Foltz  claim  this  as  the  only  case  of  the  kind  on  record. 

These  are  the  only  cases  of  foreign  bodies  escaping  from  the  umbilicus  which  we 
have  found  in  the  literature. 

*  Petrequin  et  Foltz:  Extraction  par  l'ombilic  d'une  sonde  de  femme  introduite  par  les 
voies  genitales.     Lyon  rued.,  1869,  iii,  509. 

LITERATURE  CONSULTED  ON  THE  ESCAPE  OF  FOREIGN  BODIES  THROUGH  THE 

UMBILICUS. 

Blum,  A.:  Tumeurs  del'ombilic  chez  l'adulte.    Arch.  gen.  de  mod.,  Paris,  1876,  6.  ser.,  xxviii,  151. 

Petrequin  et  Foltz:  Extraction  par  l'ombilic  d'une  sonde  de  femme  introduite  par  les  voies  geni- 
tales.    Lyon  med.,  1869,  iii,  509. 

Weiss,  E.:  Leber  diverticulare  Nabelhernien  und  die  aus  ihnen  hervorgehenden  Xabelfisteln. 
Inaug.  Di— .,  'lie-sen,  1868. 


CHAPTER  XXIII. 
UMBILICAL  TUMORS. 

Hypertrophy  of  the  umbilicus. 

Angiomata  of  the  umbilicus;  report  of  cases. 

Umbilical  lymphocele. 

Myxomata. 

Fibromata;   report  of  cases. 

Papillomata;   report  of  cases. 

Lipomata. 

Dermoids  or  atheromatous  cysts;  report  of  cases. 

Umbilical  tumors  consisting  chiefly  of  sweat-glands. 

An  abdominal  tumor  attached  to  the  inner  surface  of  the  umbilicus  by  a  pedicle  two  inches  in 

diameter. 
Papilloma  of  the  umbilicus  secondary  to  papilloma  of  the  ovary. 


Benign : 


UMBILICAL  TUMORS. 


Hypertrophy. 

Angiomata. 

Lymphocele. 

Benign  comiective-tissue  growths. 

Myxomata. 

Fibromata. 

Papillomata.  * 

Lipomata. 
Dermoid  cysts. 
Sweat-gland  tumors. 

Abdominal  myoma  springing  from  the  umbilicus. 
Papilloma  secondary  to  growth  in  ovary,  f 
Aclenomyomata. 

Malignant : 

Carcinoma  of  the  umbilicus. 

A    t>  •  /  1.  Squamous-cell  carcinoma. 

A.  unmary.       ^^  2    Adenocarcinoma. 

f  1.  From  the  stomach. 
2.  From  the  gall-bladder. 

,  3.  From  the  intestine. 

B.  Secondary.  j  4    From  the  ovary_ 

5.  From  the  uterus. 

6.  From  other  abdominal  organs. 
Sarcoma. 

1.  Telangiectatic  myxosarcoma. 

2.  Spindle-cell  sarcoma. 

3.  Round-cell  sarcoma. 

4.  Melanotic  sarcoma. 

*  In  the  ordinary  umbilical  papilloma  the  growth  is  caused  by  a  proliferation  of  the  stroma — 
the  squamous  epithelium  covering  the  papillae  occupies  merely  a  passive  role.  It  is  for  this  reason 
that  we  have  grouped  these  small  tumors  with  the  benign  connective-tissue  growths. 

t  These  may  or  may  not  be  malignant. 

351 


352  THE    UMBILICUS    AND    ITS    DISEASES. 

GENERAL  REMARKS. 

Many  authors  who  have  published  cases  showing  abnormalities  of  the  umbili- 
cus have  endeavored  to  classify  satisfactorily  umbilical  diseases.  Probably  one  of 
the  best  articles  on  the  subject  is  the  exhaustive  treatise  by  Nicaise,  published  in 
Paris  in  1881.  In  1883  Codet  de  Boisse  gave  a  satisfactory  resume  of  the  subject, 
and  the  following  year  Reginald  H.  Fitz,  of  Boston,  published  a  most  instructive 
article  in  which  he  included  lesions  of  the  umbilicus  owing  their  origin  to  persistence 
of  the  omphalomesenteric  duct. 

Villar,  in  1886,  wrote  a  thesis  on  umbilical  tumors,  going  into  the  subject  very 
carefully,  and  making  a  satisfactory  classification  of  the  various  umbilical  tumors. 
In  1890  Ledderhose  discussed  umbilical  diseases  very  fully  and  satisfactorily,  and 
in  1892  Pernice  published  his  well-known  monograph  on  Umbilical  Tumors. 
Finally,  in  1906,  Guiselin,  in  his  Bordeaux  thesis  entitled  Cancer  of  the  Umbilicus, 
outlined  a  very  practical  classification  of  umbilical  tumors.  After  reviewing  the 
literature  on  the  subject,  I  have  found  the  above  classification  the  most  satisfac- 
tory: 


LITERATURE  CONSULTED  ON  UMBILICAL  TUMORS  IN  GENERAL. 

Codet  de  Boisse:  Tumeurs  de  l'ombilic  chez  l'adulte.     These  de  Paris,  1883,  No.  311. 

Fitz,  Reginald:    Persistent  Omphalomesenteric  Remains,  Their  Importance  in  the  Causation  of 

Intestinal  Duplication,  Cyst  Formation,  and  Obstruction.     Amer.  Jour.  Med.  Sci.,  1884, 

lxxxviii,  30. 
Guiselin,  E.  J.  M.  J. :  Du  Cancer  de  l'ombilic.     These  de  Bordeaux,  1906,  No.  47. 
Ledderhose,  G. :   Deutsche  Chirurgie,  1890,  Lief.  45  b. 

Nicaise:   Ombilic.     Dictionnaire  encyclopedique  des  sc.  med.,  Paris,  1881,  xv,  140,  deuxieme  ser. 
Pernice,  Ludwig:   Die  Nabelgeschwiilste,  Halle,  1892. 
Villar,  Francis:  Tumeurs  de  1'ombilic.     These  de  Paris,  1886.  No.  19. 


HYPERTROPHY  OF  THE  UMBILICUS. 
Villar*  speaks  of  hypertrophy  of  the  umbilicus  in  a  patient  sixty  years  of  age. 
Inasmuch  as  from  the  description  it  is  clear  that  there  was  a  definite  umbilical 
suppuration  and  the  histologic  examination  showed  an  inflammatory  condition, 
we  should  certainly  hesitate  to  class  the  case  as  one  of  true  hypertrophy  of  the 
umbilicus.     I  have  encountered  no  other  literature  on  the  subject. 


ANGIOMATA  OF  THE  UMBILICUS. 

Definite  literature  on  the  subject  is  very  rare. 

Virchow,  in  1862,  mentions  two  varieties  of  umbilical  fungi.  The  one  is  usually 
rich  in  blood-vessels,  bleeds  readily,  and  is  found  after  the  cord  comes  away.  It 
consists  of  granulation  tissue,  and  after  the  use  of  astringents  soon  disappears. 
He  is  evidently  referring  to  the  simple  granulation  tissue  not  infrequently  noted 
after  the  cord  comes  away. 

The  second  variety  represents  a  congenital  tumor,  and  in  the  majority  of  cases 
is  a  remnant  of  the  omphalomesenteric  duct.  Virchow  then  refers  to  cases  reported 
by  Maunoir  and  Lawton. 

*  Villar:   Op.  cit.,  p.  76. 


UMBILICAL    TUMORS.  353 

Xicaise  refers  to  the  subject  and  mentions  three  cases  from  the  literature. 

Ledderhose  briefly  refers  to  angiomata  of  the  umbilicus,  and  says  that  cases 
have  been  recorded  by  Maunoir,  Chassaignac,  Lawton,  Boyer,  and  Colombe. 

Kidd  and  Patteson,  in  1889,  in  an  article  on  Capillary  Angioma  of  the  Umbili- 
cus, reported  a  case  in  a  child  six  weeks  old.  From  the  description,  however,  it 
would  seem  probable  that  the  tumor  consisted  of  granulation  tissue  and  was  not  an 
angioma  in  the  accepted  sense  of  the  word,  although  it  must  be  admitted  that 
granulation  tissue  in  itself  at  times  has  such  a  rich  capillary  blood-supply  that  it 
might  with  propriety  be  called  an  angioma. 

Pernice,  in  his  exhaustive  monograph  on  Tumors  of  the  Umbilicus,  briefly 
considers  the  cases  recorded  in  the  literature.  He  also  refers  to  a  case  recorded  by 
Boyer.  A  nine-3rear-old  girl  from  her  birth  had  had  an  umbilical  tumor  largely 
made  up  of  varicose  veins.  This  tumor  was  pedunculated,  like  a  polyp,  grew 
slowly,  was  bluish  in  color,  and  felt  soft.  After  being  repeatedly  tied  off,  it  com- 
pletely disappeared. 

Robson,  in  1872,  reported  a  somewhat  complicated  tumor  of  the  umbilicus 
occurring  at  birth.  The  soft  and  elastic  portion  of  the  tumor  was  of  a  dirty,  livid 
color  and  probably  represented  an  area  of  hemorrhage  and  not  a  genuine  angioma. 
The  essential  points  in  the  case  are  as  follows : 

The  mother  of  the  child  was  delivered  before  Robson  arrived,  but  he  noticed 
an  abnormal  condition  at  the  umbilicus,  three  distinct  tumors  resting  on  the 
abdomen,  and  connected  with  the  umbilicus  close  to  the  integument  of  the  navel. 
The  one  containing  the  cord  was  about  the  length  and  circumference  of  a  one-ounce 
quinin  jar,  with  a  continuation  of  a  small,  shriveled  cord  projecting  from  its  ex- 
tremity. The  under  part  of  this  tumor  consisted  of  firm,  compact  tissue;  the  upper 
was  soft  and  elastic,  without  any  pulsation,  and  of  a  dirty,  livid  color.  Immediately 
beneath  and  growing  from  the  first,  at  its  junction  with  the  abdomen,  was  a  second 
tumor  consisting  of  a  transparent,  globular  mass  the  size  of  a  large  orange,  and  a 
third,  the  size  of  a  pullet's  egg,  containing  a  thick,  albuminous  substance  like 
jelly.     The  growths  were  extirpated. 

The  tumor  consisted  mainly  of  the  cord  in  a  spiral  form,  each  coil  adhering  to 
the  other  and  thoroughly  agglutinated  by  the  albuminous  substance.  There  was 
extravasation  of  blood,  with  here  and  there  organized  matter. 

In  the  cases  reported  by  Chassaignac,  Lawton,  and  Colombe,  a  definite  angioma 
of  the  umbilicus  existed.  The  first  two  were  noted  in  infants,  but  Colombe's  case 
occurred  in  an  adult. 

As  seen  from  the  detailed  report,  when  Chassaignac's  patient  was  twelve  days 
old,  a  minute  nodule  was  noted  at  the  umbilicus.  At  six  months  the  tumor  was  as 
large  as  a  hen's  egg  and  was  non-pedunculated;  the  overlying  skin  had  a  bluish 
tinge,  and  beneath  the  surface  a  varicose  network  of  veins  could  be  seen.  Where 
the  veins  were  very  near  the  surface,  the  bluish  tinge  of  the  skin  was  naturally  more 
accentuated.  A  large  vein  appearing  to  the  left  of  the  xiphoid  passed  downward 
to  the  umbilicus  and  was  continuous  with  the  tumor. 

Lawton's  observation  was  made  on  a  new-born  child,  and  in  addition  to  the 
tumor  there  was  an  umbilical  hernia.  The  tumor  was  the  size  of  a  jargonelle  pear, 
and  darkish  in  color.  It  was  of  the  consistence  of  placental  tissue.  On  micro- 
scopic examination,  it  was  found  to  be  composed  chiefly  of  the  ramifications  of 
large  blood-vessels  held  together  by  areolar  tissue. 
2-i 


35-1  THE    UMBILICUS    AND    ITS    DISEASES. 

Colombe's  patient,  when  twenty-six  years  old,  noticed  a  small  tumor  the  size 
of  a  grain  of  wheat  at  the  umbilicus.  It  gradually  increased  in  size,  was  purple  and 
soft.  When  seen  ten  years  later,  it  was  the  size  of  the  end  phalanx  of  the  little 
finger.  Two  years  before  coming  under  observation  she  had  had  a  hemorrhage 
from  the  tumor  lasting  two  days.  The  bleeding  was  controlled  by  styptics.  Three 
days  before  admission  the  hemorrhage  recurred  and  the  bleeding  was  so  excessive 
that  the  patient  showed  marked  constitutional  symptoms. 

The  cases  of  Chassaignac,  Lawton,  and  Colombe  are  so  interesting  that  I  report 
them  in  detail: 

An  Erectile  Venous  Tumor  Developing  in  the  Region 
of  the  Umbilicus  in  a  Child  Six  Months  Old.*  —  The  child 
was  six  months  old.  To  the  left  of  the  umbilicus  was  attached  a  tumor  the  size 
of  a  small  hen's-egg.  This  was  regular,  non-pedunculated,  raising  the  left  half  of 
the  umbilical  margin  and  the  skin,  and  giving  the  overlying  skin  a  bluish  tinge. 
The  surface  of  the  tumor  was  evidently  made  up  of  a  network  of  varicose  veins 
(subcutaneous),  and  had  three  or  four  small  spots  where  the  bluish  tint  was  more 
marked.  Another  bluish  spot,  with  the  diameter  of  a  50-centime  piece,  had  occupied 
the  summit  of  the  tumor.  This  was  crescentic,  with  the  hollow  of  the  crescent 
directed  upward  and  toward  the  median  line.  A  large  vein  appearing  to  the  left 
of  the  xiphoid  passed  downward  to  the  umbilicus  and  evidently  was  continuous 
with  the  tumor. 

Pressure  on  the  tumor  produced  pallor,  but,  when  the  finger  was  raised  again, 
the  color  returned  with  increasing  intensity. 

The  mother  noticed,  twelve  or  thirteen  days  after  birth,  a  small  spot  the  size  of 
a  pin-head  at  the  umbilicus.  A  bandage  was  applied,  but  the  spot  increased  in  size 
and  became  thickened.  It  was  removed  satisfactorily.  The  tumor  consisted  of 
two  parts — adipose  tissue  and  blood-vessels  surrounded  by  cellular  tissue.  The 
vessels  were  very  abundant,  and  in  several  places  showed  varicose  dilatations. 
This  tumor  was  an  angioma. 

A  Case  of  Vascular  (Erectile)  Tumor  in  the  Sheath 
of  the  Cord  in  a  New-born.  —  Mr.  Lawtonf  was  called  to  the  delivery 
of  a  fine  male  child,  and  when  he  proceeded  to  tie  the  cord,  he  found  a  tumor  the 
size  and  shape  of  a  medium  jargonelle  pear  with  its  neck  communicating  with  the 
cavity  of  the  abdomen  through  the  umbilical  opening  and  strongly  adherent  to  the 
cord,  the  covering  being  common  to  both.  Mr.  Lawton  divided  the  cord  above  the 
tumor  in  the  usual  way.  On  examination  the  growth  felt  tough,  rather  fleshy,  and 
somewhat  like  a  placenta  might  feel  before  degeneration  commences — it  did  not 
feel  at  all  like  intestine,  although  when  the  child  cried,  both  it  and  the  investing 
membrane,  together  with  the  tegumentary  portion  of  the  umbilicus,  enlarged  very 
much — the  tumor  from  being  engorged  with  blood  and  the  membrane  from  pro- 
trusion of  intestine.  Pressure  reduced  the  one  and  somewhat  decreased  the  size 
of  the  other. 

After  reduction  of  the  hernia,  pressure  was  applied  by  means  of  a  pad  and  ban- 
da^-,  and  it  was  resolved  to  wait  and  see  what  might  be  the  termination  of  the 
case  if  left  to  nature,  as  it  was  thought  that  the  tumor  might  dry  up  and  slough 
with  the  cord.     After  a  day  or  two  affairs  presented  nearly  the  same  appearance  as 

*  Chassaignac,  M.  E.:  Traite  de  l'ecrasement  lineaire,  Paris,  1856,  535. 
t  Lawton:  London  Obstet.  Trans.,  1866,  vii,  210. 


UMBILICAL   TUMORS.  355 

at  first,  and  Mr.  Lawton  determined  to  explore  a  little.  He  did  so  by  carefully  dis- 
secting (over  the  fundus  of  the  tumor)  the  outer  covering,  when  a  clear,  yellow 
serum  escaped.  He  then  made  a  small  opening  into  the  second  covering,  and 
blood  of  a  dark  color  flowed  pretty  freely.  A  pad  and  bandage  were  immediately 
applied,  and  the  case  was  allowed  to  take  its  course  for  two  days  more.  On  enter- 
ing the  room  on  the  third  day  the  smell  of  the  decomposing  membranes  was  strong, 
and  the  integument  around  the  umbilicus  much  inflamed.  The  umbilical  open- 
ing was  large  enough  to  receive  four  fingers,  and  was  more  or  less  oval. 

At  the  lower  end  protruded  a  knuckle  of  gut;  at  the  upper  end,  a  non-pulsating, 
pyriform  tumor,  and  at  the  right-hand  side,  the  cord,  between  the  knuckle  of  gut  and 
tumor.  The  membranes  were  gangrenous  and  the  fundus  of  the  tumor  was  bare. 
It  presented  a  dark  color;  to  the  touch  it  felt  firm,  unless  strongly  compressed,  when 
it  somewhat  diminished  in  size  and  was  a  little  flaccid.  The  crying  of  the  child 
gave  now  no  impetus  to  the  tumor. 

Lawton  resolved  to  return  the  protruded  intestine,  and,  after  applying  a  ligature 
around  the  neck  of  the  tumor,  to  excise  it.  After  chloroform  had  been  given,  a 
finger  and  thumb  were  applied  to  the  neck  of  the  growth  and  fully  compressed  it. 
The  operator  made  a  slight  incision  in  the  fundus  of  the  tumor,  and  on  careful  re- 
laxation of  the  pressure,  the  blood  was  inclined  to  flow  very  freely.  A  ligature  was 
then  applied  around  the  neck  of  the  growth,  but  the  membranes,  being  gangrenous, 
it  cut  through  them,  and,  the  abdominal  muscles  becoming  rigid  at  the  same  time, 
from  eight  to  ten  inches  of  gut  protruded.  The  tumor  was  excised  above  the  liga- 
ture, the  cord  tied  as  low  down  as  possible,  and  after  careful  and  patient  manipulation 
the  protruded  intestine  was  returned.  The  opening  was  closed  as  far  as  possible 
by  passing  through  four  common  needles  in  place  of  harelip  pins;  a  pad  and  ban- 
dage were  applied  in  the  usual  way.  The  child's  bowels  were  not  moved  for  three 
days  after  the  operation,  when  they  acted  freely.  The  little  patient  had  no  bad 
symptoms,  and  at  the  time  of  the  report  was  quite  well. 

Microscopic  examination  by  Dr.  J.  Braxton  Hicks  showed  that  the  whole  mass 
was  penetrated  by  large  blood-vessels,  of  the  ramifications  of  which  it  was  princi- 
pally composed,  coupled  with  areolar  tissue,  in  the  network  of  which  were  nucleated 
cells  of  round  or  oval  form,  generally  in  groups  of  four  or  five.  There  was  in  some 
parts,  however,  an  excess  of  the  connective-tissue  elements  so  as  to  form  solid  por- 
tions.    The  tumor  was  an  angioma. 

A  Vascular  Tumor  of  the  Umbilicus.*  —  The  patient  was  a 
woman,  thirty-six  years  of  age,  in  good  health.  She  had  had  a  child  at  nineteen. 
Ten  years  before  she  had  noticed  a  small  tumor  the  size  of  a  grain  of  wheat  at  the 
umbilicus.  It  had  gradually  increased  in  size.  It  was  purple,  rather  soft,  painless, 
but  made  her  uncomfortable.  About  the  week  before  she  was  seen,  it  was  the  size 
of  the  end  of  the  phalanx  of  the  little  finger.  Two  years  before  there  had  been  a 
hemorrhage  from  the  tumor,  the  bleeding  coming  in  jets  of  the  diameter  of  a  pin. 
The  hemorrhage  lasted  two  days,  was  not  continuous,  and  was  controlled  by  per- 
chorid  of  iron.  Three  days  before  admission  she  had  a  second  hemorrhage  and 
perchloric!  of  iron  was  used,  the  flow  ceasing  just  as  the  astringent  was  employed. 
The  volume  of  bleeding  could  be  compared  to  that  from  the  femoral  artery;  the 
bleeding,  however,  was  intermittent.     The  patient  was  in  a  sea  of  blood.     She  was 

*  Colombe:    Tumeur  vasculaire  de  l'ombilic,  hemorrhagic,   guerison.    Gaz.  med.  de  Paris, 
1887,  lviii,  245. 


356  THE    UMBILICUS    AND    ITS    DISEASES. 

pale  and  apparently  in  a  serious  condition.  Forceps  were  applied,  and  the  area 
ligated  en  masse,  but  with  difficulty,  as  the  bleeding  came  from  the  bottom  of  the 
umbilicus.  Seven  days  later  the  bleeding  again  recurred.  A  ligature  was  applied, 
and  the  bleeding  stopped  and  never  returned.     The  tumor  disappeared. 


LITERATURE  CONSULTED  ON  ANGIOMATA  OF  THE  UMBILICUS. 

Chassaignac,  M.  E.:  Traite  de  l'ecrasement  lineaire,  Paris,  1856,  535. 

Colombe:    Tumeur  vasculaire  de  l'ombilic,  hemorrhagie,  guerison.     Gaz.  med.  de  Paris,  1887, 

lviii,  245. 
Kidd  and  Patteson:    Capillary  Angioma  of  the  Umbilicus.     Illustrated  Med.   News,  1889,  iv, 

148. 
Lawton:   Case  of  Vascular  (Erectile)  Tumor  in  the  Sheath  of  the  Cord  in  a  New-born.     London 

Obstet.  Trans.,  1866,  vii,  210. 
Ledderhose,  G.:   Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Nicaise:    Ombilic.     Dictionnaire   encyclopedique   des   sc.  medicales,    Paris,  1881,  2.  ser.,    xv, 

140. 
Pernice,  L.:   Die  Nabelgeschwulste,  Halle,  1892. 

Robson,  R.:   Disease  of  the  Funis  Umbilicalis.     Medical  Examiner,  Chicago,  1872,  xiii,  33. 
Virchow:   Die  krankhaften  Geschwulste,  1862-63,  hi,  erste  Halfte,  467. 


UMBILICAL  LYMPHOCELE. 

Koeberle,*  in  1878,  speaking  of  ovarian  cysts,  said  that  sometimes  the  lym- 
phatic vessels  beneath  the  umbilicus  take  on  an  excessive  development  and  the 
umbilicus  becomes  the  site  of  a  tumor  consisting  exclusively  of  the  sac-like  dilata- 
tions of  the  lymphatic  vessels. 

Codet  de  Boisset  quotes  a  letter  from  Koeberle  to  Blum  in  which  Koeberle  stated 
that  in  his  Cases  49  and  50  he  had  removed  growths  of  this  character  when  operat- 
ing for  ovarian  tumors.  One  of  these  umbilical  tumors  was  8  cm.  in  diameter. 
He  further  drew  attention  to  the  fact  that  similar  tumors  had  never  been  described. 
They  are  evidently  very  rare,  as  I  have  not  found  mention  of  any  in  the  literature. 
In  a  very  large  series  of  patients  from  whom  ovarian  tumors  have  been  re- 
moved at  the  Johns  Hopkins  Hospital  we  have  never  seen  umbilical  growths  of 
this  character. 


BENIGN  CONNECTIVE-TISSUE  GROWTHS  OF  THE  UMBILICUS. 

Under  this  head  are  included  myxomata,  fibromata,  papillomata,  and  lipomata. 
As  a  rule,  papillomata  are  classified  with  epithelial  growths.  In  umbilical  papil- 
lomata, however,  the  connective-tissue  growth  is  the  essential  feature,  the  epithelium 
playing  a  passive  role.  I  have  accordingly  included  them  under  connective-tissue 
growths. 

Myxomata  of  the  Umbilicus. 

These  tumors  are  exceptionally  rare.  According  to  Ledderhose, J  Weber  col- 
lected three  cases — those  of  Fischer-Coin,  Busch,  and  his  own.  In  Busch's  case  the 
tumor  was  the  size  of  a  goose's  egg.     Its  surface  was  ulcerated. 

*  Koeberle:  Nouveau  dictionnaire  de  med.  et  de  chir.  prat.,  1878,  xxv,  522. 
t  Quoted  by  Pernice:  Die  Nabelgeschwiilste,  Halle,  1892,  21. 
%  Ledderhose,  G.:  Deutsche  Chirurgie,  1890,  Lief.  45  b. 


UMBILICAL    TUMORS.  357 

Mori*  described  a  sessile  umbilical  tumor  the  size  of  a  cherry,  which  had  ulcer- 
ated at  its  most  prominent  part.  Histologically,  it  consisted  of  fibrous  and  myxo- 
matous tissue.     He  gives  a  very  good  picture  of  the  microscopic  appearance •-. 

In  Pernice'sf  monograph  will  be  found  the  best  description  of  this  class  of  um- 
bilical tumors.  He  says  that  myxoma  of  the  umbilicus  was  first  described  by 
Weber,  and  was  supposed  to  originate  from  portions  of  Wharton's  jelly.  The  ren- 
dition is  very  rare,  only  nine  cases  being  found  in  the  literature.  On  section  the 
tumors  look  like  white  pork,  are  pale,  edematous,  and  gelatinous.  Some  are  soft. 
others  hard,  according  to  the  amount  of  connective  tissue.  They  vary  in  size  from 
that  of  a  hazelnut  to  that  of  a  goose's  egg.  In  four  cases  the  tumors  were  peduncu- 
lated and  the  pedicle  came  directly  from  the  umbilical  scar.  In  two  cases  the 
tumors  lay  on  the  top  of  an  umbilical  hernia.  Pernice  points  out  that  only  the  cases 
since  Weber's  time  have  been  examined  microscopically.  The  blood-vessels  are 
abundant.  The  vessel- walls  are  thick  and  lie  in  a  connective-tissue  framework 
consisting  chiefly  of  spindle-cells  and  sometimes  of  round-cells.  There  is  an  inter- 
cellular substance.  In  other  words,  the  ground-substance  is  like  that  encountered 
in  embryonic  tissue.  Most  of  these  tumors  are  covered  over  with  normal  skin, 
and  only  rarely  is  the  surface  ulcerated.     The  prognosis  is  good. 

Pernice  then  goes  on  to  record  cases  reported  by  Weber,  Maunoir,  Chassaignac. 
Lawton,  Villar,  Virchow,  and  Leydhecker.  In  only  a  few  of  the  cases  are  the  micro- 
scopic reports  of  any  value. 

Fibromata  of  the  Umbilicus. 

Growths  of  this  character  are  likewise  rare.  Although  the  majority  occur  in 
middle  life  and  in  males,  they  are  sometimes  found  in  infants.  The  size  of  the 
tumors  reported  varied  greatly.  One  was  as  large  as  a  bird's  egg,  another  the  size 
of  a  walnut,  another  as  large  as  an  apple.  The  largest  was  said  to  be  the  size  of 
an  infant's  head  at  term.  They  are  usually  oval  or  round  and  more  or  less  pedun- 
culated, the  pedicle  springing  from  the  umbilical  depression.  Sometimes,  how- 
ever, the  umbilicus  may  be  recognized  as  an  irregular  slit  in  the  center  of  the  tumor. 

The  growth  is  usually  covered  with  normal  or  slightly  atrophic  skin.  On  account 
of  the  exposed  site  of  the  tumor,  its  more  prominent  surface  may  be  excoriated, 
presenting  blackened  points;  or  the  injured  areas  may  be  covered  with  crusts. 

On  section,  the  growth  usually  presents  a  grayish-white  or  whitish-yellow  sur- 
face, with  a  definite  fibrous  arrangement.  In  a  few  instances  one  or  more  small 
cysts  containing  serous  fluid  were  found,  or  a  small  quantity  of  fat  was  detected 
in  the  tumor. 

Histologic  examination  shows  that  the  skin  covering  the  growth  is  normal  or 
atrophic,  or  that  there  is  some  thickening  of  the  squamous  layers.  In  the  last  type 
the  papilla?  are  much  elongated.  The  stroma  of  the  tumor  consists,  as  a  rule,  of 
typical  fibrous  tissue  containing  a  varying  number  of  spindle-shaped  nuclei.  Some 
of  the  growths,  particularly  where  there  has  been  an  irritation  of  the  surface,  show 
marked  small-round-cell  infiltration  in  the  vicinity  of  the  point  or  points  of  such 
irritation.  Here,  as  in  other  parts  of  the  body,  the  diagnosis  between  a  very  cellu- 
lar fibroma  and  a  spindle-cell  sarcoma  is  fraught  with  much  difficulty  or  is  impossible. 

*  Mori,  A. :  Contribute)  alio  studio  dei  tumori  ombelicali.  Gazzetta  degli  ospedali,  Milano, 
1902,  xxiii,  632. 

f  Pernice:  Die  Nabelgeschwulste,  Halle,  1892. 


358  THE    UMBILICUS    AND    ITS    DISEASES. 

On  account  of  the  rarity  of  this  condition,  I  append  those  cases  in  which  the 
diagnosis  of  fibroma  of  the  umbilicus  was  certain,  or  at  least  highly  probable. 

Cases  of  Fibroma  of  the  Umbilicus. 

Fibroma  of  the  Umbilicus.  —  Legrand*  reported  from  Sappey's 
service  the  case  of  a  man  fifty-one  years  of  age.  When  the  patient  was  thirty-nine 
years  old  a  tumor  the  size  of  a  hazelnut  had  been  observed  at  the  umbilicus.  This 
was  soft  and  covered  with  skin  of  a  natural  color.  For  five  months  before  the  patient 
came  under  observation  it  had  been  increasing  rapidly,  becoming  more  than  two- 
thirds  larger.  Later,  small  excoriations  were  noticed  on  the  surface.  These  were 
covered  with  crusts. 

On  admission  to  the  hospital  an  ovoid  tumor,  about  seven  or  eight  inches  in  its 
vertical  diameter,  was  found  in  the  umbilical  region.  It  was  somewhat  peduncu- 
lated, and  with  the  patient-  lying  down  reached  to  within  1  cm.  of  the  xiphoid. 
The  pedicle  was  inserted  in  the  umbilical  scar.  The  tumor  itself  was  hard,  smooth, 
round,  and  in  its  right  third  bossed  and  ulceiated.  In  other  portions  it  was  covered 
with  brownish-yellow  crusts  alternating  with  a  purple  discoloration  of  the  skin. 
At  some  points  fluctuation  was  noted,  but  there  was  no  hemorrhage  from  the  sur- 
face. The  patient's  general  condition  was  good.  The  tumor  was  removed  and 
recovery  followed.  The  tumor  on  section  was  whitish  in  color,  homogeneous,  and 
very  hard.  It  contained  a  small,  cyst-like  cavity  with  serous  fluid  contents.  Robin, 
who  made  the  histologic  examination,  said  that  it  was  a  fibroplastic  tumor  and  not 
a  cancer. 

A  Fibro  nucleated  Tumor  at  the  Umbilicus. f  —  The 
patient  was  thirty  years  of  age,  and  the  tumor  had  been  noticed  for  three  months. 
On  admission  to  the  hospital  in  April,  1857,  the  tumor  was  the  size  of  an  orange 
and  situated  beside  the  umbilicus.  It  had  evidently  developed  in  the  umbilical 
wall,  and  was  firm  and  fibrous  in  character.  The  general  health  was  good.  On 
histologic  examination  the  tumor  was  found  to  be  composed  of  fibrous  tissue. 
Bryant  draws  attention  to  the  fact  that  such  tumors  are  evidently  rare. 

Fibrolipoma  of  the  Umbilicus. J  —  Hugh  G.,  aged  thirty,  seven 
years  before  had  noticed  a  small  lump  about  the  size  of  a  walnut  at  the  site  of  the 
navel.  It  increased  gradually  for  two  years,  when  a  surgeon,  probably  a  quack, 
"put  it  back,"  but  it  soon  returned.  Until  six  months  before  Barton  saw  him  the 
tumor  had  increased  only  gradually,  but  since  then  had  doubled  in  size.  It  was  so 
large  that  it  prevented  the  patient  from  walking.  It  was  oval,  and  extended  across 
the  abdomen  from  the  umbilicus  to  the  left  anterior  superior  spine.  It  was  slightly 
constricted  at  its  base,  measured  23  inches  in  circumference,  and  was  fixed  to  the 
skin  only  at  the  umbilicus.  On  removal  it  was  found  attached  to  the  underlying 
tissue  at  only  one  point.  The  abdomen  was  not  opened.  No  histologic  examina- 
tion is  mentioned. 

Fibromata  of  the  Umbilicus.  — ■  Damalix§  treats  the  subject  in 
general,  and  says  that  Sappey  and  Limange  report  cases  in  which  the  pedicle 
came  from  the  umbilicus. 

*  Legrand:  Tumeur  volumineuse  de  la  region  ombilicale  de  nature  fibroplastique,  prise  pour 
une  tumeur  encephalo'ide.     Gaz.  des  hop.,  1850,  29. 

t  Bryant,  T.:  Guy's  Hospital  Reports,  1863,  ix,  245. 

%  Barton:  Reported  by  Bennett:  Dublin  Jour.  Med.  Sci.,  1882,  lxxiv,  239. 

§  Damalix:  Etude  sur  les  fibromes  de  la  paroi  abdominale  anterieure.  These  de  Paris,  1886, 
No.  148. 


UMBILICAL   TUMORS.  359 

A  F  i  b  r  o  m  a  of  the  Umbilicus.  *-^A  woman,  twenty- two  years  of 
age,  entered  the  Hotel-Dieu  on  May  20,  1888.  In  February,  1887,  one  month 
after  her  child  had  been  weaned,  an  umbilical  tumor  was  first  noticed.  This  was 
the  size  of  a  hazelnut,  and  could  be  rolled  between  the  fingers.  For  a  time  it  grew 
slowly,  but  after  six  months  rapidly. 

At  the  umbilical  site  was  a  tumor  the  size  of  the  head  of  a  child  at  term.  Its 
summit  was  divided  by  the  distended  umbilical  cicatrix.  The  tumor  was  hard, 
with  several  points  of  softening.  It  was  irregular  and  bossed.  The  skin  covering 
was  normal,  without  any  marked  dilatation  of  the  veins.  It  slid  readily  over  the 
tumor. 

The  growth  was  easily  dissected  out,  but  was  found  intimately  adherent  to  the 
peritoneum.     Recovery  followed. 

The  tumor  was  hemispheric,  irregular,  about  10  cm.  in  diameter;  it  had  a 
whitish  surface,  and  presented  an  irregular,  bossed  appearance  in  the  depth,  where 
there  were  several  depressions  dividing  it  into  lobules.  On  section  it  was  whitish 
and  smooth ;  in  the  deeper  portion,  yellowish  in  color.  Here  it  had  a  definite  fibrous 
arrangement. 

Histologically,  the  tumor  was  composed  exclusively  of  fibrous  tissue,  wavy 
threads  for  the  most  part  running  parallel  to  one  another,  but  with  no  character- 
istic arrangement.  The  cells  were  abundant  and  in  general  well  developed.  They 
were  fusiform  in  shape.  The  tumor  seemed  to  have  originated  from  the  aponeuro- 
sis.    It  was  a  fibroma. 

Fibrous  Tumors  in  the  Umbilicus.  —  Pernicef  says  this  form 
of  tumor  cannot  be  sharply  differentiated  histologically  from  those  of  inflammatory 
origin.  It  may  originate  from  three  different  parts  of  the  umbilicus:  (1)  From  the 
dense  connective  tissue  of  the  umbilical  scar;  (2)  from  that  of  the  skin  which,  as 
we  have  seen,  is  really  scar  tissue  covered  with  epithelium ;  (3)  in  young  individuals 
from  myxomatous  connective-tissue  remains  of  the  cord. 

Fibroma  of  the  Umbilicus  [?].|  —  This  case  occurred  in  Volkmann's 
private  practice.  E.  H.,  aged  forty-two,  had  at  the  umbilicus  a  hard,  slightly 
lobulated,  broad-based  tumor  the  size  of  an  apple.  This  was  thought  to  be  a 
fibroma.  On  histologic  examination,  however,  it  proved  to  be  a  spindle-cell  sar- 
coma. The  spindle-cells  were  relatively  small  and  had  large  nuclei.  The  abdomen 
was  not  opened.  The  woman  was  well  at  the  end  of  ten  years.  [A  sarcoma  oc- 
curring in  the  abdominal  wall  is  so  intimately  associated  with  the  surrounding  tissue 
that  one  would  hardly  expect  a  permanent  recovery,  such  as  occurred  in  this  case. 
This  fact  would  rather  indicate  a  cellular  fibroma. — T.  S.  C] 

A  Fibroma  of  the  Umbilicus[?].§  —  A  man,  forty-nine  years  of 
age,  entered  Polaillon's  service  at  the  Hotel-Dieu  March  25,  1895.  Eighteen 
months  before  he  had  noticed  at  the  umbilicus  small  tubercles,  which  had  caused 
pain  and  inconvenience. 

Attached  to  the  lower  border  of  the  umbilicus  was  a  pedunculated  tumor, 
cylindric  in  form,  5  cm.  long  and  12  or  13  mm.  in  diameter.  Its  free  end  showed 
a  small  crust  covering  a  healed  area  of  ulceration.     The  skin  covering  it  was  deli- 

*  Pic,  Adrien:  Lyon  med.,  1888,  lix,  546. 

t  Pernice,  L.:  Die  Nabelgeschwi'ilste,  Halle,  1892.  t  Pernioe,  L. :  Op.  cit.,  obs.  69. 

§  Sourdille,  Gilbert :  Sarcome  pedicule  de  la  peau  de  l'ombilie.     Bull,  de  la  Soc.  anat.  de  Paris, 
1895,  lxx,  302. 


360  THE    UMBILICUS    AND    ITS    DISEASES. 

cate  and  reddish  in  color.  On  taking  the  tumor  between  the  fingers  it  gave  the 
sensation  of  the  finger  of  a  glove  filled  with  nuts.  The  skin  surrounding  the  tumor 
contained  seven  or  eight  pinkish  tubercles  about  the  size  of  green  peas.  The  skin 
alone  was  involved,  as  the  tumor  was  movable  on  the  underlying  aponeurosis. 
No  enlarged  glands  were  detected,  and  the  general  health  was  good.  The  diseased 
area  was  removed.  Histologic  examination  of  the  main  tumor  and  of  the  small 
nodules  showed  sarcoma  fusocellulare  covered  with  skin.  The  superficial  half  of 
the  skin  seemed  to  have  been  the  starting-point  of  the  tumor,  which  tended  to  pass 
out  and  become  pedunculated. 

[The  growth  may  equally  well  have  been  a  fibroma  associated  with  secondary 
small  nodules.     The  microscopic  examination  is  not  conclusive. — T.  S.  C] 

Probably  a  Fibroma  of  the  Umbilicus.*  —  J.  W.,  ten  months 
old,  was  brought  to  the  clinic  February  27,  1896.  He  had  remains  of  the  omphalo- 
mesenteric duct  at  the  umbilicus,  as  recognized  by  a  reddish  tumor  covered  with 
intestinal  mucosa.  In  addition  there  was  a  smooth,  cap-like  area  partly  covering 
this  reddish  tumor,  which  was  composed  chiefly  of  fibrous  tissue  (Fig.  124,  p.  209). 
[Evidently  a  true  fibroma. — T.  S.  C] 

A  Small  Fibroma  Associated  with  an  Umbilical  Con- 
cretion. —  Coenenf  reports  cholesteatomata  of  the  umbilicus,  and  in  his  Fig. 
2  shows  a  definite  but  small  fibroma  occupying  the  umbilical  cicatrix.  It  is  covered 
over  with  many  layers  of  squamous  epithelium.  The  central  portion  consists  of 
fibrous  tissue,  and  scattered  throughout  it  are  many  small  round-cells,  indicating- 
recent  inflammation.  The  inflammatory  reaction  was  evidently  started  up  by  the 
umbilical  concretion  (Fig.  151,  p.  252). 

Papillomata  of  the  Umbilicus. 

Probably  the  first  case  of  this  character  recorded  was  that  of  Fabricius  von 
Hilden,  published  in  1526.  From  that  time  on  isolated  cases  of  papilloma  of  the 
umbilicus  have  been  recorded,  but,  as  in  the  majority  of  these  no  microscopic 
examination  was  made  and  as  the  gross  picture  was  not  sufficiently  convincing,  we 
have  omitted  most  of  these,  confining  our  attention  chiefly  to  those  cases  in  which 
a  careful  histologic  description  has  been  given.  Most  of  the  tumors  have  been 
noted  between  the  twenty-fifth  and  fiftieth  years.  In  Broussolle's  case,  however, 
in  a  child  only  two  months  old,  a  typical  papilloma,  5  mm.  in  diameter,  occupied 
the  umbilical  depression.  Ordinarily  one  would  consider  this  small  nodule  in  such 
a  young  individual  as  a  mass  of  granulation  tissue  left  after  the  cord  had  come  away, 
or  as  a  remnant  of  the  omphalomesenteric  duct.  Broussolle,  however,  distinctly 
says  that  its  surface  was  covered  with  squamous  epithelium  analogous  to  that  of 
the  skin. 

From  the  limited  number  of  cases  it  is  difficult  to  draw  any  definite  conclusion, 
but  papillomata  seem  to  be  equally  frequent  in  both  sexes. 

As  a  rule,  they  are  of  slow  growth  and  vary  from  5  mm.  in  diameter  to  the  size 
of  a  walnut.  They  are  usually  pedunculated,  but  in  the  case  reported  by  Peraire 
the  papillary  growth  had  spread  out  for  a  considerable  distance  into  the  surrounding- 
abdominal  wall. 

*  Sauer,  F.:  Ein  Fall  von  Prolaps  eines  offenen  Meckel'schen  Divertikels  am  Nabel. 
Deutsche  Zeitschr.  f.  Chir.,  1896-97,  xliv,  316. 

t  Coenen,  H.:   Das  Nabelcholcsteatom.     Miinch.  med.  Wochenschr.,  1909,  56.  Jahrg.,  1583. 


UMBILICAL   TUMORS.  361 

Where  the  growth  is  small,  it  frequently  looks  red  and  reminds  one  of  a  rasp- 
berry, and  on  examination  with  a  magnifying-glass  it  is  found  to  be  composed  of 
blunt  papillary  masses.  As  the  growth  increases  in  size  the  portion  near  the  pedicle 
may  have  a  violet  tint,  while  the  superficial  portion  is  pinkish  in  color. 

In  Segond's  case,  reported  by  Villar,  the  growth  consisted  of  rounded  projections 
varying  greatly  in  size.  The  largest  nodule  was  bean-shaped  and  contained  a  small 
cyst;  another  was  the  size  of  a  pea,  and  lying  between  them  were  smaller  ones. 
As  a  rule,  when  the  tumor  reaches  its  full  size  it  resembles  a  large  wart.  Its  surface 
is  covered  with  myriads  of  papillae,  and  these  are  flattened  laterally,  owing  to  the 
close  juxtaposition.  On  section  the  papillary  or  tree-like  arrangement  is  clearly  evi- 
dent, and  the  stroma  of  the  nodule  and  of  its  pedicle  is  seen  to  consist  of  fibrous  tissue. 

Histologic  examination  shows  that  the  surface  of  the  papillae  is  covered  with 
squamous  epithelium,  in  which  epithelial  pearls  can  occasionally  be  demonstrated. 
Where  there  has  been  much  irritation,  the  epithelium  may  be  thickened  and  the 
skin  papillae  greatly  lengthened.  The  stroma  of  the  papillary  growth  consists  of 
fibrous  tissue.  Just  beneath  the  epithelium  this  may  show  marked  infiltration  and 
greatly  dilated  blood  capillaries.  The  general  appearance,  both  macroscopically 
and  microscopically,  is  similar  to  that  of  skin  papillomata  in  any  part  of  the  body. 

Cases  of  Papilloma  of  the  Umbilicus. 

Papillomata  of  the  Umbilicus[?].  —  Kiister*  cites  a  case  seen 
by  Fabricius  von  Hilden  and  recorded  in  1526.  A  man,  twenty-five  years  of  age,  well 
nourished,  had  a  fungating  excrescence  at  the  umbilicus  which  had  developed  in 
about  six  months.  The  tumor  was  the  size  of  a  walnut,  bright  red  in  color,  and 
emitted  an  odor  like  that  of  foul  cheese.  At  first  it  was  painless;  later  there  were 
severe  pain  and  two  hemorrhages.  Fabricius  considered  the  growth  a  carcinoma. 
On  exposing  the  tumor  he  found  that  it  consisted  of  three  portions,  each  with  a 
delicate  pedicle.     He  ligated  the  pedicles  and  the  patient  was  well  five  months  later. 

[This  does  not  seem  to  have  been  carcinoma,  but  suggests  rather  a  papilloma 
with  inflammation  of  the  umbilicus  due  to  accumulation  of  foul  material.  Of 
course,  at  that  time  no  histologic  examination  was  made. — T.  S.  C] 

In  Kuster's  Case  8  a  man,  thirty-six  years  of  age,  had  had  a  specific  ulcer  on 
the  glans  penis  eight  months  before.  Six  weeks  prior  to  observation  he  noticed 
that  the  umbilicus  was  moist.  In  the  left  umbilical  fold  was  a  small  tumor  which 
grew  rapidly.  Astringents  proved  of  no  value.  On  examination,  in  the  left  side 
of  the  umbilical  cavity  was  a  pedunculated  tumor  the  size  of  a  phalanx  of  the  little 
finger;  it  was  movable,  and  discharged  a  foul-smelling  fluid.  It  was  covered  with 
small  red  bodies  (papillae)  and  looked  like  a  raspberry.  When  the  umbilicus  was 
split  open  small  papillary  outgrowths  were  found  springing  from  it.  [On  histologic 
examination  the  mass  was  found  to  be  a  simple  papilloma  covered  over  with  several 
layers  of  epithelium.     In  some  places  there  were  epithelial  pearls.] 

Papilloma  of  the  Umbilicus.  —  Tillmanns,f  after  saying  that 
Kiister  had  described  a  papilloma  of  the  umbilicus,  mentions  a  case  seen  by  Wilms. 

Papilloma  of  the  Umbilicus. ±  —  In  a  woman,  fifty-four  years  of 

*  Kiister:  Die  Neubildungen  am  Nabel  Erwachsener  und  ihre  operative  Behandlung. 
Langenbeck's  Arch.  f.  klin.  Chir.,  1874,  xvi,  234. 

f  Tillmanns:  Deutsche  Zeitschr.  f.  Chir.,  1882-83,  xviii,  161. 
%  Demarquay:  Bull,  de  la  Soc.  de  chir.,  1870-71,  2.  ser.,  xi,  209. 


362  THE    UMBILICUS    AND    ITS    DISEASES. 

age,  a  tumor  developed  from  a  congenital  umbilical  nevus.  This  tumor  became 
excoriated,  and  there  was  a  discharge  of  bloody  fluid.  It  reached  the  volume  of 
an  egg,  and  two  enlarged  glands  were  noted  in  the  inguinal  region.  The  tumor 
and  the  glands  were  removed.  Demarquay  says  the  inguinal  glands  were  not 
malignant,  but  that  the  enlargement  was  due  to  irritation  from  the  growth.  On 
histologic  examination  the  growth  proved  to  be  a  papilloma. 

Papilloma  of  the  Umbilicus.*  —  The  patient,  a  concierge, 
forty-three  years  of  age,  a  year  before  he  entered  the  hospital  had  noticed  an  irri- 
tation of  the  umbilicus.  In  the  umbilical  depression  there  were  small  elevations 
the  size  of  pinheads.  They  had  gradually  increased  in  size,  until  six  months  later 
the  tumor  had  emerged  above  the  level  of  the  umbilical  depression  and  there  were 
excoriations.  At  operation  the  growth  was  the  size  of  a  franc  piece,  round,  with  a 
narrow  base.  Microscopic  examination  showed  that  it  was  a  fibropapilloma  of  the 
umbilical  cicatrix. 

Papilloma  of  the  Umbilicus.  —  Broussollef  reported  a  case  of  a 
child,  two  months  old,  who  suffered  from  suppuration  at  the  umbilicus.  There  was 
a  minute  umbilical  tumor,  reddish  in  color,  5  mm.  in  diameter.  Microscopic 
examination  showed  that  it  was  a  true  papilloma  composed  of  connective  tissue 
only  slightly  organized.  Its  surface  was  covered  with  squamous  epithelium  analo- 
gous to  that  of  the  skin. 

Papilloma  of  the  Umbilicus. |  —  This  case  was  communicated 
to  Villar  by  E.  Launois.  M.  H.,  aged  forty-six,  was  operated  upon  by  Dr.  Segond 
for  a  very  large  fibroma  of  the  uterus.  At  the  umbilicus  also  she  had  a  lobulated 
tumor,  which  occupied  all  the  cavity  of  the  umbilical  depression.  This  tumor  had 
first  been  noticed  six  years  previously.  It  had  increased  slowly  in  volume,  its 
development  occurring  chiefly  in  the  appearance  of  small  lobules.  The  mass  was 
very  tender  on  pressure  and  on  palpation.  On  examination  it  was  found  to  consist 
of  a  series  of  small  elevations  juxtaposed  to  one  another.  Above  and  below  were 
two  rounded  masses.  The  upper  one  was  the  size  of  a  pea,  the  lower  one  presented 
the  form  and  volume  of  a  bean.  Between  the  two  were  other  lobules.  The  surface 
of  the  two  voluminous  portions  was  covered  with  skin  which  had  retained  its  charac- 
teristic appearance,  but  was  wrinkled.  The  small  granulations  had  a  blackish- 
violet  appearance.  At  first  sight  the  growth  suggested  a  melanotic  tumor.  The 
umbilical  nodules  were  included  in  the  abdominal  incision  when  the  uterine  tumor 
was  removed. 

At  the  base  of  the  tumor  were  a  number  of  vascular  orifices  distended  with  blood. 
The  mass,  which  was  the  size  of  a  pea,  consisted  of  a  small  cyst  containing  yellowish 
liquid. 

Histologic  Examination. — The  tumor  was  divided  into  three  fragments.  The 
fir-t  contained  the  cyst  which  has  been  described.  The  walls  were  composed  of 
dense  connective  tissue.  At  several  points  in  the  cyst  were  remnants  of  epithelium. 
The  second  fragment  comprised  all  the  small  elevations  between  the  two  larger  ones. 
They  were  composed  of  a  series  of  papillae.  Each  papilla  was  formed  of  dense 
connective  tissue  containing  a  few  nuclei.     The  skin  covering  the  surface  presented 

*  Nicaise,  M. :   Fibro-papillome  de  la  cicatrice  ombilicale.     Revue  de  chir.,  Paris,  1883,  iii,  29. 
t  Broussolle,  E.:    Des  vegetations  de  I'ombilic.     Revue  mens,  des  mal.  de  l'enfance,  1886, 
iv.  314.  ' 

%  Villar:  Tumeura  de  I'ombilic.     These  de  Paris,  1886,  obs.  38,  p.  71. 


UMBILICAL   TUMORS.  363 

the  usual  characteristics.  The  Malpighian  layer  was  thicker  than  usual,  and  many 
cells  contained  yellowish-brown  pigment.  In  each  of  the  papillae  were  numerous 
capillary  vessels  anastomosing  with  one  another.  The  third  fragment  consisted 
of  the  inferior  elevation,  and  was  much  larger  than  the  first;  it  was  formed  of  dense 
connective  tissue,  and  the  skin  covering  was  somewhat  thinner.  The  entire  growth 
was  evidently  a  papilloma. 

Papilloma  of  the  Umbilicus.  —  Ledderhose*  says  that  Rizzoli 
had  a  patient,  fifty-one  years  old,  with  an  ulcerating  papilloma  at  the  umbilicus 
which  was  removed  with  zinc  paste. 

Fibropapilloma  of  the  Umbilicus. f  —  M.  K.,  a  fireman,  aged 
thirty-five,  three  months  before  admission  and  shortly  after  a  blow  in  the  umbilical 
region,  had  noticed  a  small  tumor  at  the  umbilicus.  This  had  steadily  increased 
in  size,  and  latterly  caused  much  inconvenience  and  at  times  a  dull,  throbbing  pain. 
The  umbilical  cavity  was  completely  obliterated  by  a  prominent,  firm  growth  the 
margin  of  which  was  continuous  with  the  skin  of  the  abdominal  wall.  This  growth 
was  circular,  with  a  diameter  of  1%  inches.  Its  surface  presented  a  warty  appear- 
ance, and  was  covered  with  elongated  papillary  growths  varying  in  size  and  flattened 
laterally  by  mutual  compression.  The  surface  of  the  tumor  was  pinkish  in  color, 
intact,  and  free  from  discharge  of  any  kind. 

This  prominent  and  warty  growth  was  seated  on  and  continuous  with  a  very 
hard,  thick  growth  extending  all  around  and  into  the  umbilicus,  and  forming  a  sub- 
jacent swelling  about  three  inches  in  diameter.  The  whole  mass  was  freely  movable 
in  all  directions.  When  the  growth  was  removed,  the  abdomen  was  examined  and 
found  perfectly  normal. 

On  section  the  tumor  was  of  a  dull  white  color,  and  its  substance,  which  was  of 
almost  cartilaginous  hardness,  was  directly  continuous  without  well-defined  mar- 
gins. It  had  extended  into  the  surrounding  fat  and  other  tissue.  .  The  peritoneum 
was  adherent  to  the  tumor  and  drawn  up  into  it.  The  entire  tumor  presented  to 
the  naked  eye  an  appearance  very  similar  to  that  of  a  recent  specimen  of  cancer 
of  the  mamma. 

On  histologic  examination  it  was  found  to  consist  of  fibrous  tissue  fully  devel- 
oped.    The  growth  was  a  so-called  fibropapilloma. 

[Smith's  description  is  a  particularly  good  one. — T.  S.  C] 

Papillary  Fibromata  of  the  Umbilicus.  —  In  the  literature 
Pernice|  found  only  seven  definite  cases  of  papilloma  of  the  umbilicus,  and  he  added 
one  from  the  Halle  clinic.  [These  cases  did  not  impress  us  very  definitely  as  being 
instances  of  simple  papilloma.]  Pernice  says  that  the  outer  surface  of  the  pap- 
illoma, as  well  as  the  stroma,  is  similar  to  that  found  in  other  parts  of  the  body. 
Where  an  ulcerated  papilloma  of  the  umbilicus  exists,  a  lymphatic  swelling  of  the 
inguinal  glands  may  follow,  but  this  does  not  necessarily  indicate  that  carcinoma 
exists.  Where  a  papilloma  is  not  pedunculated,  the  diagnosis  may  be  difficult  prior 
to  operation.  The  clinical  course  of  papilloma  is  benign  throughout.  He  then 
goes  on  to  report  the  cases  of  Kuster,  Weber,  Billroth,  Blum,  Villar,  and  mentions 
some  reported  by  Duges.  In  very  few  of  these  is  it  absolutely  clear  that  a  careful 
histologic  examination  was  made.     In  a  second  case  of  Kuster 's  the  microscopic 

*  Ledderhose:  Deutsche  Chirurgie,  1890,  Lief.  45  b. 

t  Smith,  J. :   The  Lancet,  1890,  i,  1013. 

%  Pernice,  L. :  Die  Nabelgeschwtilste,  Halle,  1892. 


364  THE    UMBILICUS    AND    ITS    DISEASES. 

examination  showed  that  the  growth  was  a  simple  papilloma.  Pernice  also  reports 
some  rather  indefinite  cases  from  the  clinic  at  Halle. 

Pernice  says  that  when  his  article  was  already  in  the  printer's  hands  he  had  an 
opportunity  of  seeing  a  rare  case  of  papilloma  of  the  umbilicus  observed  in  a  patient 
coming  under  the  care  of  Dr.  Harttung,  of  Frankfort.  This  patient  was  a  woman, 
fifty-two  years  old,  very  corpulent,  and  previously  healthy.  Four  years  before,  the 
umbilicus,  which  was  markedly  funnel-shaped,  had  commenced  to  be  moist.  The 
patient  was  not  cleanly.  After  some  time  there  was  a  reddening  in  the  depth  with 
much  irritation  and  itching,  which  caused  the  patient  to  rub  the  umbilicus.  Later 
on  a  wart-like  appearance  was  noted.  The  secretion  was  much  more  abundant, 
and  the  patient  complained  of  pain. 

On  examination  the  umbilicus  was  found  to  be  much  drawn  in,  very  much  red- 
dened, and  there  were  excoriated  places  on  the  skin  about  the  size  of  a  mark.  In 
the  center  of  this  eczematous  area  was  the  umbilicus.  It  was  covered  with  a  large 
number  of  papillary-like  growths,  each  being  about  the  size  of  half  a  grain  of  wheat. 
These  papillomata  resembled  in  their  color  and  arrangement  pointed  condylomata. 
When  the  abdominal  walls  were  drawn  apart,  a  large  number  of  smaller  papillo- 
mata were  seen  and  there  was  a  purulent  secretion. 

No  induration  could  be  made  out  at  the  base  of  the  tumor,  the  axillary  and 
inguinal  glands  were  not  swollen,  and  there  were  no  symptoms  referable  to  other 
organs. 

The  diagnosis  of  papilloma  of  the  umbilicus  was  made,  and  the  growth  removed. 
The  tumor  was  about  2  cm.  in  height  and  the  skin  of  the  part  was  raised.  From 
the  center  of  the  tumor  sprang  about  20  or  30  wart-like  growths  of  soft  consistence. 
These  were  covered  with  smooth  epidermis,  and  all  their  ends  were  somewhat 
pointed.  These  papillary  masses  filled  the  entire  umbilical  pocket,  which  was  2  to 
3  cm.  deep.     Their  epidermis  was  not  ulcerated  at  any  point. 

The  microscopic  picture  was  very  simple,  and  corresponded  identically  with  the 
picture  of  the  soft  warts — in  other  words,  the  growth  was  a  true  papilloma.  Along 
the  edge  was  perfectly  normal  skin;  toward  the  center  the  epidermis  became  thicker, 
and  between  the  papillae  of  the  skin  the  epithelial  projections  were  irregular,  some- 
times longer  and  narrower,  and  at  other  times  thick  and  plump.  The  papillary 
masses  consisted  of  a  connective-tissue  groundwork  with  an  epithelial  covering. 
The  epithelium  was  here  more  irregular,  and  sometimes  sent  prolongations  down- 
ward. The  masses  were,  however,  simple  throughout.  On  the  surface  the  horni- 
fication  was  somewhat  advanced.  The  connective  tissue  of  the  tumor  and  also  of 
the  surrounding  skin  showed  abundant  small-round-cell  infiltration. 

Papilloma  of  the  Umbilicus.*  —  R.  A.,  aged  twenty-seven,  had 
had  a  swelling  at  the  umbilicus  for  four  months,  which  discharged  a  serosanguineous 
fluid.  On  admission  a  tumor,  the  size  of  a  walnut,  was  found  situated  in  the  center 
of  the  umbilicus.  At  its  base  it  had  a  violet  tint,  and  at  its  summit  was  grayish- 
white.  It  was  sessile,  soft,  and  round,  resembling  a  wart.  It  was  very  painful  on 
palpation.  It  was  thought  to  be  a  papillofibroma  of  the  umbilicus,  and  was 
removed  under  local  anesthesia. 

The  microscopic  examination  was  made  by  Professor  Cornil.  The  skin  was  very 
irregular  and  in  the  form  of  papillae.     The  papillae  on  the  surface  of  the  tumor  were 

*  Peraire,  Maurice:  Fibro-papillome  de  l'ombilic.  Bull,  de  la  Soc.  anat.  de  Paris,  1902, 
lxxvii,  346. 


UMBILICAL   TUMORS.  365 

very  long,  very  abundant,  tree-like,  and  formed  the  depression  penetrating  the 
connective  tissue.  They  were  composed  of  dense  connective  tissue  supporting  the 
blood-vessels  and  were  covered  with  epithelium.  Between  the  epithelial  cells 
were  leukocytes.  The  tumor  was  a  fibropapilloma  showing  inflammatory  reaction, 
Peraire  remarks  that  this  variety  of  tumor  is  rare.  Villar  reported  only  four  cases — 
those  of  Kiister,  Blum,  Nicaise,  and  Segond. 

Papilloma  of  the  Umbilicus.*  —  Mrs.  B.  C.  C,  aged  forty-two, 
a  patient  of  Dr.  W.  T.  Watson,  was  admitted  to  the  Church  Home  and  Infirmary 
October  26,  1910.  During  the  abdominal  preparation  prior  to  removing  the 
appendix  and  shortening  the  round  ligaments,  we  noticed  a  small  papillary  mass 
at  the  umbilicus.     It  was  excised. 

Gyn.-Path.  No.  15692.  The  specimen  is  5  mm.  broad,  4  mm.  long,  slightly 
pedunculated.  Its  surface  is  divided  into  three  lobules,  which  are  perfectly  smooth 
and  remind  one  very  much  of  a  small  fibroma  (Fig.  167). 

Histologic  Examination. — The  greater  part  of  the  specimen  imbibes  hematoxy- 
lin with  avidity.  The  surface  is  covered  with  very  atrophic 
squamous  epithelium,  the  superficial  portion  of  which  is  horni- 
fied.  The  deepest  layer  contains  yellowish  and  brownish  pig- 
ment in  places,  and  reminds  one  of  the  skin  of  a  colored  per- 
son, although  the  patient  is  white.  Beneath  the  epithelium 
is  a  narrow  zone  of  connective  tissue,  poor  in  cell  elements,  and 
beneath  this  again  fibrous  tissue,  literally  packed  with  cells 
containing  oval  or  round,  uniformly  staining  nuclei.  Divid- 
ing the  fibrous  tissue  into  alveoli  are  minute  arterioles.  The  fig.  167.— Small  pap- 
central  portion  of  the  specimen  is  made  up  of  fibrous  tissue  1LLOM A IN  THE  Um~ 

BILICAL        DEPRES- 

poor  in   cell   elements.     The   picture   at   first   suggests   sar-  sion. 

coma.     The  surface  epithelium  is,  however,  everywhere  in-  The  small  growth 

,  rr-M  i    •       c    ii  n  ui  i  vi  was  tabulated,  the  sur- 

tact.     1  he  nuclei  of   the  stroma  cells,  although  exceedingly       face  of  each  lobule  be_ 

abundant,  are  uniform  in  size  and  there  is  no  evidence  of       ing  relatively  smooth. 

nuclear  figures.     In  addition,  the  clinical  history  shows  that 

the  patient  had  had  this  small  nodule  for  years.     It  is  a  simple  papilloma  of  the 

umbilicus. 

LlPOMATA  OF  THE  UMBILICAL    REGION. 

In  the  umbilical  depression  there  is  little  or  no  fat,  consequently  we  should  not 
expect  to  find  any  fatty  tumors  in  this  situation.  Tillmanns,t  however,  points  out 
that  Wrany  has  drawn  attention  to  the  fact  that,  where  there  is  a  dilatation  of  the 
umbilical  ring,  some  of  the  subperitoneal  fat  may  escape  through  the  hernial  ring, 
producing  an  "  adipose  hernia  "  or  a  lipoma,  which  may  be  confused  with  an  omental 
hernia. 

A  reference  to  Levadoux'sJ  masterly  article  on  the  Anatomy  of  the  Umbilicus 
clearly  shows  just  how  such  a  hernial  protrusion  may  occur  at  or  near  the  umbilicus. 

*  Cullen,  Thomas  S.:  Personal  observation. 

f  Tillmanns:  Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring 
(Ectopia  ventriculi),  und  iiber  sonstige  Geschwiilste  und  Fisteln  des  Nabels.  Deutsche  Zeitschr. 
f.  Chir.,  1882-83,  xvhi,  161. 

\  Levadoux:  Varietes  de  l'ombilic  et  de  ses  annexes.  These  de  la  Fac.  de  med.  et  de  pharm. 
de  Toulouse,  1907,  No.  711. 


366  THE    UMBILICUS    AND    ITS    DISEASES. 

LITERATURE  CONSULTED  ON  BENIGN  CONNECTIVE-TISSUE  GROWTHS  OF  THE 

UMBILICUS. 

Barton:  Fibrolipoma  of  the  Umbilicus.     Dublin  Jour.  Med.  Sc,  1882,  lxxiv,  239. 

Bennett:   See  Barton. 

Bryant,  T. :  A  Fibronucleated  Tumor.     Guy's  Hospital  Reports,  1863,  ix,  245. 

Broussolle,  E. :  Des  vegetations  de  l'ombilic.     Rev.  mens,  des  mal.  de  l'enfance,  1886,  iv,  314. 

Coenen:  Das  Nabelcholesteatom.     Munch,  med.  Wochenschr.,  56.  Jahrg.,  1909,  1583. 

Cullen :,  Thomas  S. :  Papilloma  of  the  Umbilicus. 

Damalix:   Etude  sur  les  fibromes  de  la  paroi  abdominale  anterieure.     These  de  Paris,  1886,  No. 

48. 
Demarquay :  Cancer  de  l'ombilic.     Bull,  de  la  Soc.  de  chir.,  1870-71,  2.  ser.,  xi,  209. 
Green,  CD.:  Trans.  Path.  Soc.  of  London,  1899, 1,  243. 
Kiister,  E. :  Die  Neubildungen  am  Nabel  Erwachsener  und  ihre  operative  Behandlung.     Langen- 

beck's  Arch.  f.  klin.  Chir.,  1874,  xvi,  234. 
Ledderhose,  G.:  Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Legrand:    Tumeur  volumineuse  de  la  region  ombilicale  de  nature  fibroplastique,  prise  pour  une 

tumeur  encephaloi'de  (fibrome  de  l'ombilic).     Gaz.  des  hop.,  1850,  29. 
Mori,  A.:    Contributo  alio  studio  dei  tumori  ombelicali.     Gazz.  degli  ospedali,  Milano,  1902, 

xxiii,  632. 
Nicaise:  Fibro-papilloma  de  la  cicatrice  ombilicale.     Rev.  de  chir.,  Paris,  1883,  hi,  29. 
Peraire,  Maurice:   Fibro-papillome  de  l'ombihc.     Bull,  de  la  Soc.  anat.  de  Paris,  1902,  lxxvii,  346. 
Pernice,  L. :   Die  Nabelgeschwulste,  Halle,  1892. 
Pic,  Adrien:  Lyon  med.,  1888,  lix,  546. 
Sauer,  F.:    Em  Fall  von  Prolaps  eines  offenen  Meckel'schen  Divertikels  am  Nabel.     Deutsche 

Zeitschr.  f.  Chir.,  1896-97,  xliv,  316. 
Smith,  J.:  Fibroma  of  the  Umbilicus.     The  Lancet,  1890,  i,  1013. 
Sourdille,  G. :  Sarcome  pedicule  de  la  peau  de  l'ombilic.     Bull,  de  la  Soc.  anat.  de  Paris,  1895,  lxx, 

302. 
Tillmanns:  Deutsche  Zeitschr.  f.  Chir.,  1882-83,  xviii,  161. 
Villar,  F. :  Tumeurs  de  l'ombilic.     These  de  Paris,  1886,  No.  19. 


DERMOIDS  OR  ATHEROMATOUS  CYSTS  OF  THE  UMBILICUS.* 

Judging  from  the  number  of  cases  reported  one  would  infer  that  dermoids  at 
the  umbilicus  are  by  no  means  rare.  Nevertheless,  on  carefully  following  the 
clinical  histories  and  checking  up  the  pathologic  findings,  one  finds  that  in  nearly 
all  the  cases  the  supposed  dermoid  cyst  was  nothing  more  than  an  umbilical  con- 
cretion, in  the  majority  of  the  cases  associated  with  suppuration,  and  that  the  diag- 
nosis of  dermoid  cyst  has  erroneously  been  made  owing  to  the  presence  of  the 
sebaceous  material  and  hairs  in  the  discharge  from  the  infected  umbilicus.  Villar, 
in  1886,  pointed  out  this  erroneous  conception,  and  several  others  have  also  men- 
tioned it. 

After  carefully  analyzing  the  cases  of  supposed  dermoids  or  atheromata  of  the 
umbilicus  that  are  available  in  the  literature,  I  have  found  among  them  only  six 
that  were  true  umbilical  dermoid  cysts.  These  were  reported  by  Kiister,  Lotzbeck, 
Morestin,  Lannelongue  and  Fremont,  Hue  and  Guelliot.  These  atheromatous 
tumors  were  all  noted  in  young  patients.  In  three  they  were  found  at  birth,  in 
one  after  the  cord  came  away,  and  in  the  remaining  two  they  had  been  present  since 
childhood. 

A  dermoid  cyst  may  spring  from  the  umbilical  cicatrix  or  from  the  side  of^the 
umbilicus.     It  may  reach  the  size  of  a  walnut  and  tend  to  become  pedunculated. 

*  In  this  connection  we  used  the  words  dermoid  and  atheromatous  as  synonymous  terms. 


UMBILICAL    TUMORS.  367 

It  may  be  tense  or  occur  as  a  flaccid  sac.  It  contains  sebaceous  material,  which,  on 
histologic  examination,  yields  epithelium,  fat-droplets,  and  frequently  cholesterin 
crystals.  The  cyst-walls  examined  histologically  have  shown  an  inner  lining  of 
squamous  epithelium  devoid  of  hairs  or  glands  of  any  sort,  and  in  none  of  the  cases 
have  hairs  been  detected  in  the  cyst  contents. 

The  skin  covering  these  cysts  is,  as  a  rule,  unaltered.  In  Morestin's  case,  how- 
ever, as  a  result  of  the  rubbing  of  the  clothing,  it  had  become  reddened  at  one  point 
and  slight  suppuration  had  occurred,  followed  by  discharge  of  the  characteristic 
cyst  contents. 

Detailed  Report  of  Cases  of  Dermoid  or  Atheromatous  Cysts  of  the  Umbilicus. 

Dermoid  Cyst  at  the  Umbilicus.*  —  Case  7. — In  July,  1872, 
Kiister  saw  a  woman,  twenty-one  years  old,  who  had  a  tumor  at  the  umbilicus. 
This  had  been  noted  since  birth.  It  was  round,  soft,  and  attached  to  the  umbilicus 
by  a  pedicle.  It  sprang  from  the  left  of  the  umbilical  depression,  and  was  easily 
shelled  out.  It  had  thin  walls,  and  the  sac  was  filled  with  atheromatous  material, 
fat,  epithelial  cells,  and  cholesterin  crystals.  No  microscopic  examination  was 
made  of  the  nodule.     It  was  probably,  as  Kiister  thought,  a  dermoid. 

A  Pedunculated  Sebaceous  Cyst  of  the  Umbilicus.!  — 
A  man,  twenty-seven  years  of  age,  entered  the  service  of  Pean.  At  birth  he  had 
had  at  the  umbilicus  a  tumor  the  size  of  a  hazelnut.  Within  five  or  six  weeks  before 
he  entered,  as  the  result  of  pressure  produced  by  a  belt,  it  had  increased  to  four 
times  its  original  size;  it  had  become  red  at  its  prominent  part,  slightly  ulcerated, 
and  a  whitish,  thick,  granular,  or  clotted  material  had  escaped  from  it.  On  exami- 
nation the  tumor  was  found  to  be  the  size  and  shape  of  a  small  fig,  and  was  attached 
to  the  umbilical  cicatrix.  It  was  lax,  a  little  wrinkled,  and  gave  the  sensation  of  a 
half-empty  pouch.     It  was  not  painful  on  pressure. 

The  skin  covering  it  was  thin.  The  patient  refused  operation.  A  congenital 
sebaceous  cyst  was  diagnosed. 

Cyst  of  the  Umbilicus,  Possibly  a  Dermoid.  —  Ledder- 
hose,|  after  saying  that  the  literature  on  the  subject,  is  scanty,  refers  to  a  case 
reported  by  Lotzbeck,  in  which  Bruns  removed  a  multilocular  tumor  the  size  of  a 
fist  from  a  child  two  and  one-half  years  old.  This  had  been  noticed  immediately 
after  birth,  and  was  then  the  size  of  a  walnut.  It  contained  fluid  which  was  partly 
clear  amber  yellow,  somewhat  alkaline,  and  partly  thick,  honey-brown,  and  gel- 
atinous. The  tumor  lay  between  the  skin  and  the  rectus.  The  connective-tissue 
wall  of  the  cyst  contained  small,  thread-like,  cartilaginous  deposits,  and  was  lined 
with  a  simple  squamous  epithelium.  The  contents  were  fat,  cholesterin,  and 
numerous  cells. 

A  Congenital  Dermoid  Cyst.§  —  A  child,  nine  years  old,  pre- 
sented in  the  middle  of  the  umbilicus  a  hemispheric  protuberance  the  size  of  half 

*  Kiister:  Die  Neubildungen  am  Nabel  Erwachsener  und  ihre  operative  Behandlung. 
Langenbeck's  Arch.  f.  klin.  Cbir.,  1874,  xvi,  234. 

|  Guelliot:  Observation  de  kyste  sebace  pedicule  de  l'ombilic.  Revue  de  chir.,  1883,  iii, 
193. 

i  Ledderhose:   Deutsche  Chirurgie,  1890,  Lief.  45  b. 

§  Lannelongue  et  Fremont:  De  quelques  varietes  de  tumeurs  congenitales  de  1'ombiUc  et 
plus  specialement  des  tumeurs  adenoides  diverticulaires.  Arch.  gen.  de  med.,  1884,  7.  ser., 
xiii,  36. 


368  THE    UMBILICUS    AND    ITS    DISEASES. 

a  walnut.  The  skin  had  not  changed  color.  The  central  portion  of  the  tumor  was 
soft  and  fluctuating.  It  was  circumscribed,  but  in  the  deeper  portion  adherent. 
It  was  not  enlarged  by  crying,  was  irreducible,  and  was  found  to  be  a  cyst.  It 
had  been  noted  immediately  after  the  cord  came  away,  and  had  enlarged  rapidly 
during  the  first  five  or  six  months  of  life.  At  operation  it  was  found  to  contain 
sebaceous  material. 

A  Dermoid  Cyst  at  the  Umbilicus.  —  Hue*  noted  a  dermoid 
cyst  of  the  umbilicus  as  large  as  a  pigeon's  egg.  It  had  been  taken  for  an  umbili- 
cal hernia.  The  patient,  a  girl  of  nineteen,  had  carried  it  from  childhood, 
and  had  only  suffered  from  some  slight  inconvenience.  The  umbilical  depression 
had  been  replaced  by  this  round  tumor.  The  skin  covering  it  was  normal,  but 
the  tumor  was  attached  to  the  umbilical  cicatrix  by  a  flattened  pedicle.  It  was 
soft,  painless,  and  irreducible,  but  was  easily  removed.  At  the  meeting  of  the 
Medical  Society  Hue  showed  photographs  of  the  case.  I  wrote  asking  Dr.  Hue  if 
he  could  send  me  a  photograph  of  the  tumor.  He  replied  saying  that  the  photo- 
graphs had  been  mislaid,  but  as  soon  as  he  found  them  he  would  gladly  send  me 
one,  but  thus  far  I  have  not  received  a  second  communication  from  him. 

Deve  found  it  to  be  a  cyst  covered  over  with  normal  skin,  and  containing  a 
whitish,  creamy  material  without  any  development  of  hair.  The  cyst-wall  was 
scarcely  1  mm.  thick,  composed  of  fibrous  tissue,  and  lined  with  squamous  epi- 
thelium without  hair  or  glands  of  any  sort.  Hue  thought  it  had  originated  from  a 
nipping-off  of  a  fragment  of  skin  in  the  umbilical  cicatrix  following  the  dropping-off 
of  the  cord. 

A  Dermoid  Cyst  of  the  Umbilicus,  f  —  The  patient  was  a  male, 
nineteen  years  old.  Since  childhood  he  had  had  a  small  round  tumor  attached  to 
the  umbilicus.  A  few  days  before  Morestin  saw  him  it  had  become  tender,  more 
prominent,  and  pink  or  reddish  in  color.  It  had  occasioned  some  suffering.  On 
the  night  after  admission  a  whitish  material  was  seen  escaping  from  a  small  opening 
at  the  point  where  the  redness  had  developed. 

On  examination  the  nodule  was  found  to  be  the  size  of  a  walnut,  whitish  red, 
and  occupying  the  center  of  the  umbilical  region.  It  was  attached  by  a  pedicle 
to  the  center  of  the  umbilicus.  The  surrounding  skin  was  normal.  The  growth 
was  removed  under  local  anesthesia,  but  the  peritoneal  cavity  was  not  opened. 
The  cyst  contained  some  greasy  whitish  material.  There  were  no  hairs.  Mallet 
made  slides  and  found  an  epithelial  lining,  but  no  hairs  and  no  glands.  He  felt 
sure  that  the  tumor  was  a  dermoid  cyst. 

A  Possible  Dermoid  of  the  Umbilicus.  —  In  this  case  of 
Villar's  it  is  impossible  to  determine  accurately  whether  or  not  the  cyst  was  in 
reality  atheromatous  in  character.  It  did  not  seem  to  be  in  any  way  associated 
with  an  inflammation  of  the  umbilicus. 

Yillart  reports  a  case  of  dermoid  cyst  occurring  in  the  service  of  Professor 
Verneuil.  M.  0.,  a  Russian  officer  twenty-seven  years  old,  was  seen  in  con- 
sultation June,  1886,  for  a  small  tumor  of  the  umbilicus  situated  exactly  in  the 
left  of  the  umbilicus  and  passing  off  from  the  umbilical  depression.     The  tumor 

*  Hue,  F.:   Kyste  dermoide  de  l'ombilic.     La  Xormandie  medicale,  1909,  xxiv,  28. 
f  Morestin,  H.:  Kyste  dermo'ide  de  l'ombilic.     Bull,  de  la  Soc.  anat.  de  Paris,  1909,  annee  84, 
742. 

%  Villar:   Tumeurs  de  l'ombilic.     These  de  Paris,  1886,  66. 


UMBILICAL   TUMORS.  369 

was  the  size  of  a  walnut  and  semifluctuant.  On  pressure  it  did  not  change  in  vol- 
ume. It  had  been  present  for  a  little  more  than  two  years  and  had  not  increased 
in  size  until  a  short  while  before.  On  pressure  it  was  painful.  The  diagnosis  lay 
between  a  small  umbilical  hernia,  a  cyst,  and  a  lipoma.  The  tumor  was  opened 
with  a  bistoury  and  there  escaped  a  clear  liquid;  a  cystic  sac  remained.  The 
histologic  examination  was  made  by  Clado.  The  tumor  was  as  big  as  a  large  wal- 
nut, was  whitish  blue,  and  fibrous  in  character.  The  inner  surface  presented  a 
granular  appearance  and  had  a  caseous-like  covering;  the  contents  were  liquid 
and  seropurulent.  Microscopic  examination  showed  white  blood-corpuscles  in 
large  numbers  and  also  some  red  blood-corpuscles,  numerous  very  attenuated  hairs, 
and  small  cholesterin  crystals.  Cultures  from  the  liquid  yielded  a  diplococcus. 
Examination  of  the  cyst-wall  was  difficult.  In  the  wall  there  were  neither  glandular 
elements  nor  hair-follicles.  [The  origin  of  this  cyst  does  not  seem  to  be  perfectly 
clear.] 

LITERATURE  CONSULTED  ON  DERMOID  CYSTS  OF  THE  UMBILICUS. 

(See  also  the  literature  on  Umbilical  Concretions,  p.  260.) 

Bondi,  J.:  Zur  Kasuistik  der  Nabelcysten.     Monatsschr.  f.  Geb.  u.  Gyn.,  1905,  xxi,  729.     (From 

Schauta's  clinic.) 
Guelliot:  Observation  de  kyste  sebace  pedicule  de  l'ombilic.     Revue  de  chir.,  1883,  iii,  193. 
Hue,  F. :  Kyste  dermoiide  de  l'ombilic.     La  Normandie  medicale,  1909,  xxiv,  28. 
Ktister,  E. :  Die  Neubildungen  am  Nabel  Erwachsener  und  ihre  operative  Behandlung.     Langen- 

beck's  Arch,  f .  klin.  Chir.,  1874,  xvi,  234. 
Lannelongue  et  Fremont:    De  quelques  varietes  de  tumeurs  congenitales  de  l'ombilic  et  plus 

specialement  des  tumeurs  adenoiides  diverticulaires.  Arch.  gen.  de  med.,  1884,  7.  ser.,  xiii,  36. 
Ledderhose,  G.:  Deutsche  Chirurgie,  1890,  Lief.  45  b. 

Morestin,  H.:  Kyste  dermoi'de  de  l'ombilic.     Bull,  de  la  Soc.  anat.  de  Paris,  1909,  annee  84,  742. 
Pernice,  L. :  Die  Nabelgeschwulste,  Halle,  1892. 
Villar,  F. :  Tumeurs  de  l'ombilic.     These  de  Paris,  1886. 

UMBILICAL  TUMORS  CONSISTING  CHIEFLY  OF  SWEAT-GLANDS. 

Three  cases  have  been  recorded  in  which  the  tumor  was  supposed  to  have 
originated  in  whole  or  in  part  from  sweat-glands.  These  were  reported  by  Wull- 
stein,  von  Noorden,  and  Ehrlich. 

In  Wullstein's  and  also  in  von  Noorden's  case  there  is  some  doubt,  and  from  the 
histories  it  seems  to  me  that  the  growths  probably  originated  from  Miiller's  duct 
or  from  uterine  mucosa.  This  point  the  reader  can  decide  for  himself,  as  they  are 
reported  in  full  on  p.  384  and  p.  387. 

In  Ehrlich's  case  part  of  the  growth  consisted  of  sweat-glands,  the  remaining 
portion  of  uterine  glands.  The  sweat-glands  were  gathered  into  definite  colonies. 
Each  colony  was  embedded  in  a  stroma,  which  was  sharply  differentiated  from  the 
surrounding  stroma,  although  essentially  similar  in  character  to  it.  The  epithelium 
lining  the  glands  was  of  the  characteristic  low  cuboid  variety.  Some  of  the  glands 
were  dilated  (Fig.  176,  p.  383). 

On  page  398  I  have  referred  to  a  small  aggregation  of  sweat-glands  occurring 
in  an  adenomyoma  of  the  umbilicus  that  came  under  my  personal  observation. 

Fig.  183,  p.  398,  from  this  case  reminds  one  somewhat  of  the  gland  grouping 
found  in  fibromata  of  the  breast.  Although,  as  a  rule,  there  are  no  sweat-glands 
in  the  umbilicus,  nevertheless,  the  normal  skin  is  so  close  to  it  that  a  tumor  consist- 
25 


370  THE    UMBILICUS    AND    ITS    DISEASES. 

ing  of  sweat-glands  might  so  encroach  upon  the  umbilicus  that  it  could  not  be  dis- 
tinguished from  one  growing  in  the  umbilical  depression. 

In  the  specimen  recently  sent  me  by  Dr.  Edward  G.  Jones  of  Atlanta  I  found 
sweat-glands  and  glands  resembling  those  of  the  body  of  the  uterus.  Part  of  the 
small  umbilical  tumor,  which  was  three-quarters  of  an  inch  in  diameter,  undoubt- 
edly consisted  of  sweat-glands. 


LITERATURE  CONSULTED  ON  UMBILICAL  TUMORS  CONTAINING  SWEAT-GLANDS. 
WuUstein,  L.:  Arbeit-en  aus  dem  Path.  Inst,  in  Gottingen,  R.  Virchow,  zum  50.  Doctor-Jubilaum, 

1893,  245. 
Von  Xoorden:  Deutsche  Zeitschr.  f.  Chir.,  1901,  lix,  215. 
Ehrlich:  Arch.  f.  klin.  Chir.,  1909,  lxxxix,  742. 


AN  ABDOMINAL  TUMOR  ATTACHED  TO  THE  INNER  SURFACE  OF  THE  UMBILICUS 
BY  A  PEDICLE  TWO  INCHES  IN  DIAMETER. 

From  the  description  of  this  case  one  gathers  the  impression  that  the  tumor 
was  a  myoma.  It  may  have  been  a  myoma  that  had  engrafted  itself  upon  the  um- 
bilicus. A  few  details  in  the  description  point  to  the  possibility  that  the  growth 
was  an  adenomyoma  ("ferous  matter").  We  know  that  a  small  adenomyoma 
with  glands  identical  with  those  of  the  uterine  mucosa  may  be  found  at  the  umbili- 
cus. In  the  cases  recorded  the  growths  have  been  on  the  outer  or  skin  surface  of 
the  umbilicus,  but  there  seems  to  be  no  adequate  reason  why  they  might  not  just 
as  well  project  from  the  inner  or  peritoneal  side  of  the  umbilicus,  producing,  as  in 
this  case,  an  abdominal  tumor  with  its  pedicle  attached  to  the  umbilicus.  In  the 
umbilical  adenomyomata  reported,  however,  the  tumors  have  always  been  of  small 
size. 

A  Hydrops  Ascites  From  a  Tumor  Depending  from 
the  Navel  Internally.*  — -A  multipara,  about  forty-three  years  of  age, 
was  thought  to  be  pregnant.  After  going  a  year  she  had  labor-like  pains  for 
eighteen  hours.  Her  periods  returned  and  continued  to  be  regular  for  eight  or 
nine  months.  There  was  then  one  flooding,  after  which  no  further  periods  were 
noted.  She  complained  of  fulness  in  the  abdomen.  Six  years  later  she  was 
tapped,  large  quantities  of  fluid  being  removed  from  time  to  time. 

The  patient  finally  died.  A  large  carnous  excrescence  was  found  depending 
from  the  umbilicus  by  a  pedicle  two  inches  in  diameter.  The  tumor  was  adherent 
to  several  parts  of  the  peritoneum,  but  these  adhesions  were  easily  separated  with 
the  hand.  Xo  vessels  were  seen  except  those  in  the  pedicle  of  the  tumor.  The 
tumor  appeared  to  be  composed  of  cells  communicating  with  each  other.  Some 
contained  "ferous  matter,"  others  were  full  of  a  substance  of  the  consistence  of 
"marrow."  From  these  cells  tubes  as  large  as  goose-quills  and  full  of  the  same 
material  passed  out  into  the  umbilicus,  being  contained  in  a  thick,  muscular  sub- 
stance of  which  the  neck  of  the  tumor  was  principally  composed.  The  entire 
tumor  weighed  eight  pounds.  Nothing  widely  deviating  from  the  ordinary  struc- 
tures was  noted  in  the  abdominal  viscera. 

[At  this  time  no  careful  histologic  examinations  were  made.  The  muscular 
character  of  the  tumor,  coupled  with  the  appearance  of  "ferous  matter"  and 

*  Johnston,  William:  Medical  Essays  and  Observations,  Edinburgh,  1744,  v,  part  ii,  640. 


UMBILICAL    TUMORS.  371 

of  spaces  as  broad  as  goose-quills  filled  with  the  same  material,  strongly  sug- 
gests to  us  the  possibility  of  an  adenomyoma.  Of  course,  this  is  merely  surmise. 
The  presence  of  ascites  with  a  parasitic  myoma  is  not  of  rare  occurrence. — T.  S.  C] 


PAPILLOMA  OF  THE  UMBILICUS  SECONDARY  TO  PAPILLOMA  OF  THE  OVARY. 

This  is  the  only  case  of  this  character  of  which  we  have  any  record.  As  will  be 
noted  from  the  history,  papilloma  of  the  ovary  and  secondary  abdominal  nodules 
were  found  at  operation  in  1898.  The  patient  was  seen  from  time  to  time,  and  about 
six  and  a  half  years  later  a  small,  partially  ulcerated,  umbilical  nodule  was  removed. 
On  histologic  examination  the  superficial  portions  of  the  nodule  showed  some 
inflammatory  reaction.  The  remaining  portions  were  composed  of  papillary  masses 
covered  over  with  cylindric  epithelium  and  conforming  exactly  in  appearance  to 
the  histologic  picture  of  papilloma  of  the  ovary,  but  differing  totally  from  a  primary 
papilloma  of  the  umbilicus.  The  relatively  benign  character  of  the  growth  is 
evident,  as  the  patient  was  in  fair  condition  over  six  years  after  partial  removal  of 
the  papillary  masses  from  the  abdomen. 

Papilloma  of  the  Umbilicus  Second  a  r'y  to  Papilloma 
of  the  Right  Ovary.  — ■  Gyn.  No.  6112.  F.  M.,  a  woman,  was  admitted 
to  the  Johns  Hopkins  Hospital  on  May  18,  1898.  An  exploratory  laparotomy  was 
made,  and  a  large  sac  was  removed,  together  with  papillary  masses  from  the  peri- 
toneum. 

Path.  No.  2377.  The  growth  proved  to  be  papillary  in  origin  and  came  from 
the  right  ovary. 

Gyn.  No.  6523.     November  18,  1898:  Two  liters  of  ascitic  fluid  were  removed. 

November  13,  1899:  The  abdomen  was  opened  for  papillomata  of  the  ovary 
involving  the  peritoneum,  and  also  for  post-operative  ventral  hernia. 

Gyn.  No.  8284.  November  7,  1900:  An  exploratory  operation  was  performed, 
and  14  liters  of  ascitic  fluid  were  evacuated.  There  was  a  papilloma  of  the  right  ovary 
the  size  of  a  child's  head  and  also  papillary  growths  in  the  parietal  peritoneum. 
In  the  pelvis  was  a  subperitoneal  cystic  growth  surrounding  the  rectum  on  both 
sides.  It  did  not  seem  to  be  made  up  of  papillary  masses,  but  appeared  to  be  due 
to  an  effusion  of  serous  fluid  beneath  the  peritoneum.  The  parietal  peritoneum 
was  roughened  and  reddened. 

Gyn.  No.  8575.     March  13,  1901:  Ascitic  fluid  was  removed. 

March  20,  1901 :  The  fistulous  opening  in  the  abdominal  wall  was  excised. 

March  19,  1905 :  A  small  umbilical  nodule  was  removed  by  Dr.  Hunner. 

Path.  No.  8417.  The  superficial  portion  consists  of  granulation  tissue.  The 
surface  is  covered  with  hyaline  material  embedded  in  which  are  a  large  number  of 
polymorphonuclear  leukocytes;  beneath  this  is  canalized  fibrin,  also  containing 
polymorphonuclear  leukocytes,  and  in  the  depth  are  dilated  capillaries  surrounded 
by  young  connective-tissue  cells.  The  central  portions  are  well  organized.  The 
more  protected  parts  consist  of  typical  papillary  masses,  large  and  small.  They 
are  covered  over  with  one  layer  of  cylindric  ciliated  epithelium.  The  epithelium 
varies  considerably;  in  some  places  it  is  exceedingly  high,  and  in  others  cuboid. 
The  nuclei  may  be  oval  and  uniformly  staining,  or  oval  and  vesicular.  The  tumor 
presents  the  typical  picture  of  papilloma  of  the  ovary,  although  found  at  the  umbili- 
cus.    Some  of  the  papillary  masses  are  well  organized.     In  places  the  stroma  has 


372  THE    UMBILICUS    AND    ITS    DISEASES. 

been  replaced  by  hyaline  tissue.  In  short,  we  have  at  the  umbilicus  a  papilloma 
identical  with  an  ovarian  papilloma.  On  account  of  irritation  from  the  clothing, 
the  superficial  portion  has  become  inflamed  and  is  partly  replaced  by  granulation 
tissue.  It  is  remarkable  that  the  woman  has  lived  so  long,  particularly  with  such 
wide-spread  papillary  masses.  Some  of  these  patients,  however,  live  for  a  great 
many  years.  In  1894  I*  reported  a  case  of  double  papillocystomata  of  both  ova- 
ries. Fifteen  years  later  I  heard  from  the  same  patient.  She  was  well  and  had 
gained  49  pounds. 

*  Cullen,  Thomas  S.:  Johns  Hopkins  Hosp.  Bull,  November,  1894,  No.  43,  103. 


CHAPTER  XXIV. 
ADENOMYOMA  OF  THE  UMBILICUS. 

Historic  sketch. 
Report  of  cases. 
Personal  observations. 

UMBILICAL  TUMORS   CONTAINING  UTERINE  MUCOSA  OR  REMNANTS   OF 

MULLER'S  DUCTS.* 

While  gathering  together  from  the  literature  the  numerous  cases  of  primary 
tumor  of  the  umbilicus  I  found  several  that  did  not  seem  to  belong  to  any  of  the 
classes  hitherto  recognized,  and  yet  all  of  these  cases  in  one  or  more  points  bear  a 
certain  amount  of  resemblance  to  one  another.  Finally,  the  picture  of  this  new- 
group  became  so  firmly  fixed  in  my  mind  that  when  reading  the  description  of  a  case 
recorded  in  1899  by  Dr.  Green,  of  Romford,  England,  I  felt  so  sure  that  his  case 
came  under  this  category  that  I  wrote  him,  asking  if  perchance  he  still  had  a  section 
of  the  tumor.  An  examination  of  the  slide  which  he  kindly  furnished  me  showed 
that  we  were  right  in  our  surmise.  In  brief,  the  clinical  histories  in  this  class  of 
cases,  coupled  with  the  gross  appearances  of  the  tumors,  leave  no  doubt  that  we  are 
dealing  with  a  variety  of  umbilical  tumor  never  before  clearly  understood. 

The  composite  picture  of  such  tumors — which  were  found  only  in  women — is 
as  follows:  At  some  time  between  the  thirtieth  and  fifty-fifth  year  a  small  tumor 
develops  at  the  umbilicus,  reaching  its  full  size  in  the  course  of  a  few  months.  It 
is  usually  described  as  being  the  size  of  a  small  nut.  Sometimes  it  is  painful,  espe- 
cially at  the  menstrual  period,  and  in  at  least  one  instance  there  was  a  brownish, 
bloody  discharge  from  the  umbilicus  at  such  times. 

The  overlying  skin  is  usually  pigmented,  and  there  may  be  one  or  two  bluish 
or  brownish  cysts  just  beneath  the  skin.  These  may  rupture  and  discharge  a 
little  brownish  fluid— old  blood.  On  section  the  nodule  is  found  to  be  intimately 
attached  to  the  skin,  is  very  dense,  and  is  traversed  by  glistening  bands  of  fibrous 
tissue.  Scattered  throughout  the  nodule  one  sometimes  finds  small  spaces  pre- 
senting a  sieve-like  appearance.  These  spaces  are  filled  with  brownish  fluid. 
Occasionally  there  may  be  a  small  cyst,  several  millimeters  in  diameter,  filled  with 

*  Shortly  after  the  appearance,  in  Surgery,  Gynecology  and  Obstetrics  (May,  1912,  479),  of 
my  article  on  Umbilical  Tumors  Containing  Uterine  Mucosa  or  Remnants  of  Miiller's  Duct,  I  re- 
ceived the  following,  in  a  letter  from  Dr.  S.  W.  Goddard,  of  Brockton,  Mass.,  dated  September  10, 
1912:  "After  reading  your  recent  article  in  Surgery,  Gynecology  and  Obstetrics  on  Umbilical 
Tumors  and  noting  a  similarity  to  two  I  have  published,  I  am  sending  you  a  reprint  of  the  same  in 
hopes  that  they  may  be  of  interest  to  you,  and,  if  of  any  value,  would  be  glad  to  have  you  make  use 
of  them  in  connection  with  your  work,  as  I  infer  that  you  are  specially  interested  in  the  subject. 
I  have  not  seen  any  similar  cases  since." 

These  two  cases  reported  by  Dr.  Goddard  belong  to  the  same  group  as  those  I  have  collected. 
That  he  clearly  recognized  the  source  of  origin  of  these  glands  is  also  evident  from  the  title  of  his 
article:  Two  Umbilical  Tumors  of  Probable  Uterine  Origin.  I  had  overlooked  Dr.  Goddard's 
article  completely.  To  him  undoubtedly  belongs  the  credit  for  having  drawn  attention  to  the 
probable  origin  of  the  glands  in  these  cases.  Dr.  Goddard's  cases,  one  recently  recorded  by  Barker, 
and  one  examined  by  me  for  Dr.  Jones,  of  Atlanta,  are  recorded  at  the  end  of  the  chapter. 

373 


374  THE    UMBILICUS    AND    ITS    DISEASES. 

brownish  contents.  Exceptionally,  grayish,  somewhat  homogeneous  areas  are 
distinguishable  in  the  tumor. 

On  histologic  examination  the  superficial  squamous  epithelium  is  usually  found 
intact.  It  may  be  normal  or  thickened.  The  stroma  of  the  growth  is  composed 
of  dense  fibrous  tissue.  Sometimes  a  few  bundles  of  non-striped  muscle  are  noted 
here  and  there  in  the  fibrous  stroma.  In  other  specimens  the  non-striped  muscle 
is  much  more  abundant  than  the  fibrous  tissue. 

Scattered  throughout  the  field  are  glands,  round,  oval,  or  irregular.  They  occur 
singly  or  in  groups,  and  are  lined  with  cylindric  epithelium.  When  occurring 
singly,  they  frequently  lie  in  direct  contact  with  the  fibrous  tissue,  but  when  found 
in  groups,  are  usually  surrounded  by  a  characteristic  stroma  that  stains  more  deeply 
and  is  much  more  cellular  than  the  surrounding  fibrous  tissue.  The  cells  of  this 
stroma  between  the  glands  usually  have  oval  or  round  vesicular  nuclei.  Fre- 
quently some  of  the  glands  are  dilated  and  their  epithelium  is  somewhat  flattened. 
The  cyst  spaces,  noted  macroscopically  and  filled  with  brownish  fluid,  are  likewise 
dilated  glands,  and  the  fluid  is  old  blood.  The  stroma  around  the  glands  frequently 
shows  fresh  hemorrhage  or  remnants  of  old  blood,  to  be  recognized  by  the  deposit 
of  blood  pigment. 

From  the  above  description  it  is  clearly  seen  that  the  gland  picture  is  that  of  the 
uterine  mucosa  with  its  typical  glands  and  its  characteristic  stroma,  and  further 
that  the  typical  menstrual  reaction  is  often  present,  as  evidenced  by  the  pain  in  the 
nodule  at  the  periods,  the  accumulation  of  old  menstrual  blood  with  the  formation 
of  small  cysts,  and  in  at  least  one  instance  by  the  occasional  discharge  of  blood  from 
the  umbilicus.  In  this  case  (Fig.  168)  one  or  two  of  the  glands  opened  directly  on 
the  surface,  thus  allowing  free  escape  of  the  menstrual  blood. 

In  all,  nine  cases  have  been  recorded.  Green's  case  (Fig.  168),  Mintz's  first 
and  third  cases  (Figs.  171  and  174),  and  Ehrlich's  case  (Fig.  177)  owe  their  glandular 
origin  without  doubt  to  the  uterus  or  to  a  portion  of  Miiller's  duct  from  which  the 
uterine  mucosa  originally  comes.  Although  the  cases  reported  by  Wullstein,  Gian- 
nettasio,  von  Noorden,  and  Mintz  (Case  2)  also  probably  belong  to  the  same  group, 
the  evidence  is  not  quite  so  clear,  and  without  the  opportunity  of  carefully  studying 
the  original  sections  I  should  not  feel  justified  in  including  them  as  certain  instances. 

The  most  common  glandular  elements  at  the  umbilicus  are  remnants  of  the 
omphalomesenteric  duct.  These  are  usually  identical  in  structure  with  the  glands 
of  the  small  intestine,  and  never  give  rise  to  the  cystic  dilatations  noted  in  the  group 
of  cases  under  discussion;  moreover,  hemorrhage  into  the  stroma  is  exceptional. 
They  differ  totally  both  in  their  gross  and  histologic  appearances. 

We  have  in  this  group  of  cases  glandular  elements  that  from  their  histologic 
appearance  and  arrangement  correspond  exactly  with  those  found  in  adenomyoma 
of  the  uterus,  and  in  one  case  at  least  (Green's)  the  surrounding  stroma  was  com- 
posed chiefly  of  non-striped  muscle,  making  the  growth  essentially  an  adenomyoma. 
In  the  majority  of  the  cases,  however,  the  stroma  consisted  of  fibrous  tissue,  but 
little  muscle  being  present. 

These  growths  are  benign,  and  if  removed  in  toto,  provided  no  other  embryonic 
foci  exist,  give  rise  to  no  further  trouble.  In  Mintz's  first  case,  four  years  after  the 
first  nodule  had  been  removed,  two  others  developed.     These  were  also  extirpated. 

In  Ehrlich's  case,  in  addition  to  typical  uterine  mucosa,  there  was  a  definite 
tumor  formation  that  had  originated  from  sweat-glands. 


ADENOMYOMA    OF    THE    UMBILICUS.  375 

In  order  that  the  reader  may  gain  a  clear  insight  into  each  of  the  cases,  they  are 
reported  in  detail,  together  with  the  comments  on  each  case. 

The  descriptions  of  the  illustrations  naturally  differ  from  those  given  by  the 
various  authors.  I  have  redescribed  each  picture  in  the  light  of  our  new  knowledge 
of  the  subject. 

A  Small  Umbilical  Tumor  Containing  Uterine 
Glands.*  —  [The  author  very  kindly  placed  a  section  of  the  growth  at  my  dis- 
posal. There  is  no  doubt  that  the  gland  elements  in  this  case  are  identical  with 
those  of  the  uterine  mucosa,  as  seen  from  Figs.  168,  169,  and  170,  which  have 
recently  been  made. — T.  S.  C] 

The  patient,  a  woman  fifty  years  of  age,  had  complained  of  irritation  about  the 
umbilicus  for  about  two  and  a  half  years,  and  there  had  been  an  occasional  dis- 
charge, brownish  in  color.  When  Dr.  Green  saw  her,  fourteen  months  before  the 
growth  was  removed,  there  was  some  eczematous  irritation  of  the  skin  in  the  neigh- 
borhood, but  no  projecting  growth  could  be  observed  at  that  time.  The  bottom 
of  the  umbilical  depression  had  an  irregular,  wart-like  appearance.  The  surround- 
ing eczema  soon  yielded  to  treatment,  but  there  was  from  time  to  time  an  irritating 
discharge  from  the  umbilicus,  which  the  patient  declared  was  always  worse  during 
her  menstrual  periods. 

The  umbilicus  with  the  growth  and  a  portion  of  the  surrounding  skin  was 
removed.  The  omentum  was  not  adherent  to  the  umbilicus,  and  no  intestine  was 
seen  at  operation.  The  wound  healed  by  first  intention  and  there  was  no  subsequent 
trouble,  so  far  as  could  be  learned. 

On  microscopic  examination  the  skin  was  found  to  be  normal.  The  stroma  of 
the  growth  was  made  up  of  fibrous  tissue  and  non-striped  muscle,  scattered  among 
which,  without  any  definite  arrangement,  were  numerous  gland  elements.  Some  of 
these  were  very  near  the  free  surface,  others  more  deeply  placed.  They  were  for 
the  most  part  tubular  and  lined  with  columnar  epithelium  showing  large,  deeply 
staining  nuclei.  They  were  thought  to  be  reproductions  of  Lieberkiihn's  crypts, 
but  differed  from  them  in  their  exaggerated  dimensions.  Some  of  them  were  so 
large  that  they  might  almost  have  been  described  as  cysts.  [Dr.  Green  thought 
that  the  growth  was  a  remnant  of  the  vitello-intestinal  tract.] 

On  reading  this  history  I  noted  that  there  had  been  some  discharge  of  blood  from 
the  umbilicus,  as  indicated  by  the  brownish  color,  and,  furthermore,  that  the  patient 
had  always  been  worse  at  the  menstrual  periods.  This  made  me  suspect  the  possible 
presence  of  uterine  glands  at  the  umbilicus.  I  wrote  Dr.  Green  and  early  in  July 
received  the  following  reply: 

The  Ferns,  Romford,  England,  June  22,  1911. 
Dear  Sir:  In  reply  to  your  query  about  my  case  of  umbilical  growth,  I  am  pleased 
to  be  able  to  send  you  a  section  from  the  same,  so  that  you  may  form  your  own  judg- 
ment as  to  its  histology.  I  did  not  think  it  was  malignant.  I  last  heard  of  the 
patient  two  and  a  half  years  after  the  operation.  She  was  then  alive  and  well. 
This,  I  think,  shows  that  the  growth  was  not  secondary  to  an  undiagnosed  growth 
within  the  abdomen.  Owing  to  removal,  I  have  not  subsequently  heard  of  her,  so 
I  cannot  say  what  ultimately  happened  to  her.  I  inclose  a  copy  of  my  paper  which 
I  happened  to  have  kept. 

Yours  faithfully, 

Charles  D.  Green. 

*  Green,  Charles  D. :  A  Case  of  Umbilical  Papilloma  Which  Showed  Some  Activity  of  Growth 
in  a  Patient  Fifty  Years  of  Age  and  Which  was  Due  Apparently  to  Inclusion  of  a  Portion  of 
Meckel's  Diverticulum.     Trans.  Path.  Soc.  London,  1899, 1,  243. 


376 


THE    UMBILICUS    AND    ITS    DISEASES. 


We  were  particularly  fortunate  in  obtaining  this  specimen  from  Dr.  Green,  in 
the  first  place,  because  it  was  twelve  years  since  the  case  had  been  reported,  and, 


IffF 


Fig.  168. — A  Small  Umbilical  Tumor  Containing  Glands  and  Stroma  Identical  with  Those  of  the  Uterine 

Mucosa. 
The  slide  was  kindly  furnished  me  by  Dr.  Charles  D.  Green,  of  Romford,  England,  and  is  from  the  umbilical  growth 
reported  by  him  in  the  Transactions  of  the  Pathological  Society  of  London,  1899.  The  squamous  epithelium  is  intact, 
and  apart  from  some  thickening  appears  normal.  Scattered  throughout  the  underlying  stroma  are  oval,  round,  or 
irregular  glands  occurring  singly  or  in  groups;  there  are  also  a  few  cystic  spaces.  Some  of  the  glands  lie  directly  be- 
neath the  skin.  At  c  two  of  the  glands  open  directly  upon  the  surface  of  the  umbilicus.  Area  A  has  been  enlarged  and 
is  shown  in  Fig.  169.  The  increased  magnification  of  area  B  is  seen  in  Fig.  170.  The  photomicrographs  of  this  series 
were  made  by  Mr.  H.  H.  Hart. 

in  the  second  place,  because  it  is  one  of  the  most  valuable  cases  of  this  character 
thus  far  on  record. 

Dr.  Green's  specimen,  No.   125. — The  skin  surface  is  intact  and  practically 
normal,  although  at  a  few  points  the  epithelium  is  considerably  thickened.     In 


ADENOMYOMA    OF    THE    UMBILICUS. 


377 


one  or  two  places  directly  beneath  the  skin  there  is  small-round-cell  infiltration, 
chiefly  in  foci.  At  one  point  the  surface  epithelium  extends  a  short  distance  into 
a  cavity  (Fig.  168,  c).  In  the  lower  portion  of  the  cavity  the  lining  consists  of 
cylindric  epithelium,  one  layer  in  thickness.  Around  this  area  the  stroma  shows  a 
considerable  amount  of  hemorrhage.  It  is  from  this  point  that  there  was  undoubt- 
edly bleeding  at  the  menstrual  periods.  The  underlying  stroma  consists  to  a  large 
extent  of  non-striped  muscle.     Scattered  here  and  there  throughout  the  muscle 


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Fig.  169. — Glands  from  a  Small  Umbilical  Tumor. 
The  picture  is  an  enlargement  of  the  area  A  in  Fig.  168.     The  normal  character  of  the  surface  epithelium  is  clearly 
seen.     The  gland  spaces  vary  considerably  in  size  and  shape  and  are  lined  with  cylindric  epithelium.     Those  in  the 
picture  lie  in  direct  contact  with  the  dense  surrounding  stroma. 


are  glands.  They  are  small,  round,  oblong,  irregular,  or  large  (Fig.  169).  A  few 
of  them  occur  singly  and  lie  in  direct  contact  with  the  surrounding  stroma.  The 
majority,  however,  occur  in  groups  or  in  chains,  and  are  separated  from  the  sur- 
rounding stroma  by  a  definite  stroma  of  their  own  (Fig.  170),  which  is  recognized 
by  its  deeper  stain  and  its  abundance  of  vesicular  nuclei,  which  are  oval  or  round. 
Some  of  the  glands  are  very  much  dilated.  Where  such  dilatations  have  taken 
place  the  surrounding  stroma  frequently  shows  a  good  deal  of  hemorrhage. 


378 


THE    UMBILICUS    AND    ITS    DISEASES. 


Were  it  not  for  the  presence  of  the  skin  surface  one  would  immediately  diagnose 
the  specimen  as  an  adenomyoma  of  the  uterus.  The  picture  is  typical,  as  seen  from 
Figs.  168,  169,  and  170.  The  growth  is  an  adenomyoma  of  the  umbilicus.  Dr. 
Green  at  the  time  felt  sure  that  the  condition  was  a  rare  one,  as  indicated  from  a 
second  communication  dated  August  4,  1911: 

Dear  Dr.  Cullen:  ....  I  am  glad  you  found  my  specimen  so  interesting. 
I  had  some  photographs  prepared,  but  the  Committee  of  the  Pathological  Society 
did  not  think  them  of  sufficient  interest  to  insert  them  in  the  Transactions.  I  was 
a  little  disappointed  at  the  time,  for  I  thought  that  the  condition  was  uncommon. 

Yours  faithfully, 

Charles  D.  Green. 


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Fig.  170. — Typical  Uterine  Mucosa  in  a  Small  Umbilical  Ttjmob.  An  Enlargement  op  Area  B  in  Fig.  168. 
The  three  large  glands  in  the  right-hand  part  of  the  picture,  in  shape  and  arrangement,  resemble  those  found  in 
an  adenomyoma  of  the  uterus:  separating  them  from  the  dense  tumor  growth  is  a  definite  and  characteristic  stroma. 
The  group  of  glands  in  the  middle  of  the  picture  is  even  more  characteristic,  one  of  the  glands  being  dilated.  All  are 
lined  with  cylindric  epithelium,  and  the  contrast  between  the  surrounding  stroma  and  the  dense  growth  is  very  clearly 
marked.     Afl  noted  in  the  description,  non-striped  muscle  was  found  scattered  throughout  the  nodule. 


[On  looking  up  the  Transactions,  I  found  that  two  of  the  committee  diagnosed 
the  growth  as  a  columnar-cell  carcinoma,  but  whether  primary  or  secondary  they 
were  unable  to  decide.  The  chairman  of  the  committee  said  some  of  the  members 
present  who  examined  the  specimen  were  not  inclined  to  regard  it  as  malignant. 
There  is  little  wonder  that  at  that  time  confusion  existed,  and  had  it  not  been  for 
the  specially  favorable  opportunity  I  had  had  of  examining  so  many  cases  of  adeno- 
myoma, I  should  have  undoubtedly  overlooked  the  true  origin. — T.  S.  C] 


ADENOMYOMA    OF    THE    UMBILICUS.  379 

Adenomyoma  of  the  Umbilicus.*  —  Case  1  .  —  In  1883  a 
woman  acquired  an  umbilical  hernia  after  labor.  Ten  years  later,  within  the  space 
of  about  two  months,  a  dark-blue  tumor  the  size  of  a  hazelnut  developed  on  the 
umbilical  elevation.  This  had  two  cystic  areas  on  its  surface.  During  menstrua- 
tion the  tumor  swelled  and  the  cysts  ruptured.  They  contained  blood-tinged  fluid. 
The  tumor  was  extirpated  and  the  hernia  repaired.  This  tumor  on  section  pre- 
sented a  cavernous  appearance,  but  no  microscopic  examination  was  made.  In 
1897,  four  years  later,  there  was  a  return  of  the  hernia,  and  at  the  umbilicus  were 
two  hard  nodules  about  the  size  of  hazelnuts.  On  microscopic  examination  they 
were  found  to  contain  glands  lined  with  cylindric  epithelium  and  surrounded  by  a 
definite  stroma.  Here  and  there  bundles  of  non-striped  muscle  were  in  evidence. 
The  dilated  glands  contained  blood-pigment.  Mintz  thought  he  was  dealing 
with  remains  of  the  omphalomesen- 
teric duct.  --     "ishh^^h 

[When  discussing  this   case  some 
three  years  ago,  just  after  making  the  •':••• 

abstract,  I  made  the  following  note: 
"The  clinical  history,  the  macroscopic 
appearance,  the  picture  of  the  glands, 
the  stroma,  and  the  contents  of  the 
dilated    glands   all   point    to    acleno-  ) 

myoma,  although  adenomyoma  of  the  I    , 

umbilicus  has  never  been  reported." 
— T.  S.  C] 

We  are  fortunate  in   again   hear-  J     ,,.     r,  „         TT 

=>  -blG.    171. (jr  LANDS     IN    A     SMALL      I  MB1LICAL     TCMOR. 

ing  from  Mintz  on  this  subject.     Ten  (Mintz,  Case  i.) 

years     later     he     published     an     article  The  outlying  connective-tissue  stroma  is  very  ir- 

.,     ,      (it\  -y    U    1      1  "AT  regular.     Occupying  the  lower  half  of  the  field  are  glands 

entitled         DaS    JNabeladenom,        Arch.  showing  some  branching.     They  are  lined  with  one  layer 

f.  klin.   Chil*.      1909     lxxxix     385.       Here  of  cylindric  epithelium  and  lie  in  a  characteristic  stroma 

,  .  .,  .         i    j.    -i     -i-1,       l,"  which  separates  them  from  the   fibrous  tissue  of  the 

he    CieSCriDeS,    more    in    detail,   the    hlS-  tumor.    The  entire  picture  reminds  one  to  a  large  extent 

tologic  findings  Of   the  Same  Case.       He  of  adenomyoma  of  the  uterus. 

says : 

' '  The  ground  substance  of  the  growth  consists  of  connective  tissue  not  very  rich 
in  cells.  They  cross  one  another  or  run  parallel  with  one  another  in  cords.  Here 
and  there  in  the  scar  tissue  one  sees  gland  tubules  in  either  transverse  or  longitudinal 
section.  They  are  surrounded  by  young,  very  cellular  connective  tissue,  which 
passes  very  gradually  into  the  old  scar  tissue.  The  glands  are  lined  with  one  layer 
of  cylindric  epithelium.  Their  lumina  are  collapsed  and  contain  blood  pigment  or 
reddish-colored  contents  (Fig.  171).  In  some  places  the  tubules  lie  close,  at  other 
points  the}r  are  separated.  The  newly  formed  connective  tissue  surrounding  them 
has  changed  into  old  connective  tissue  poor  in  cell  nuclei.  Some  of  the  glands  are 
dilated  and  their  epithelium  is  flattened.  The  lumina  appear  to  be  filled  with 
detritus.  Here  and  there  the  cylindric  epithelium  is  unrecognizable  and  the  cavity 
contains  blood-pigment  (Fig.  172).  W'here  the  dilatation  has  occurred,  the  epi- 
thelium has  disappeared;  in  this  way  are  to  be  explained  the  cysts  with  blood 
contents  which  were  noted  when  the  patient  first  entered  the  hospital.  Between 
the  glandular  portion  of  the  tumor  there  are  at  some  points  groups  of  non-striped 

*  Mintz,  W.:  Das  wahre  Adenom  des  Xabels.     Deutsche  Zeitschr.  f.  Chir.,  1899,  li,  545. 


380  THE    UMBILICUS    AND    ITS    DISEASES. 

muscle-fibers  that  have  no  definite  topographic  arrangement  in  relation  with  the 
glands.  The  microscopic  examination  shows  an  adenomatous  growth  in  the  scar 
tissue.  This  has  stimulated  the  growth  of  the  scar  tissue,  and  thus  originated  the 
young  connective  tissue  surrounding  the  new  glands.  In  the  mean  time  the 
periphery  of  the  nodule  in  the  scar  has  been  converted  into  sarcoma." 

[After  giving  this  description  he  says  in  a  foot-note  that  at  the  time  of  writing 
(that  is,  ten  years  later)  the  tumor  had  not  returned.  The  explanation  of  the  origin 
of  this  tumor  he  gives  as  persistent  remains  of  the  omphalomesenteric  duct  which 
had  remained  latent  for  forty-two  years  in  the  umbilical  scar,  and  under  the  in- 
fluence of  chronic  injury  (a  ten-year  persistent  umbilical  hernia)  had  given  rise  to 
adenoma. 

It  can  hardly  be  doubted  that  we  are  dealing  with  an  adenomyoma,  although 
such  a  case  had  heretofore  never  been  described.  We  have  the  increase  in  size  at 
the  menstrual  period,  the  cysts  with  blood  contents,  glands  resembling  uterine 
glands,  the  characteristic  stroma  of  the  mucosa  surrounding  the  glands,  that  was 

thought  by  Mintz  to  be  sarcomatous,  and 
the  fact  that,  after  the  second  operation, 
the  patient  remained  absolutely  well  for 
-  -     -      U  ten  years.     How  these  glands  originated 

at  the  umbilicus  we  do  not  attempt  to  ex- 
\  plain.    We  have,  however,  found  them  in 

the  inguinal  region,  and  I  feel  confident 
\  that,  in  the  course  of  time,  somebody  will 

"""-..  get  a  clear  chain  of  evidence  showing  how 

remnants  of  the  uterus  can  reach  the  um- 
bilicus.—T.  S.  C] 

Fig.  172. — Dilated  Glands  in  a  Small  Umbilical  a      a  ™  „  1  i      TT  m  b  i  1  i  C  8  1      T  U  m  O  r 

Tumor.     (Mintz,  Case  1.) 

In  the  center  of  the  field  is  a  very  much  dilated  C  O  n  t  a  i  11  i  11  g      U  t  e  r  1  11  e       G  1  a  11  d  S  . 

gland.     Its  epithelium  is  flattened.     The  gland  itself  is  C  a  S  e    2     (Mintz) . The  WOllian  Was 

separated  from  the  surrounding  stroma  by  a  definite,  ,  -,  .    ,  •    i   ,  r  tt<i  j-L. 

dark-staining  zone.     As  noted  in  the  history,  the  dilated  thirty-eight  years  of  age.     Eleven  lllOUths 

gland  cavities  in  the  tumor  contained  exfoliated  epithe-  before,  a  myomatous  uterUS  had  beeil  re- 
lium,  granular  material,  and  in  some  instances  blood.  i     xi  i_  i    i  l     •       •    • 

moved  through  an  abdominal  incision. 

Eight  months  later  she  noticed  at  the 
umbilicus  a  tumor  which  increased  in  size  for  three  months  and  then  stopped  growing. 
During  menstruation  there  was  pain  in  the  tumor.  From  the  umbilicus  to  the  sym- 
physis there  was  an  operation  scar.  At  the  umbilicus  was  a  conic  tumor  with  its  base 
high  in  the  umbilicus.  The  tumor  extended  for  2  cm.  above  the  surface  of  the  abdo- 
men, and  was  covered  with  pigmented  skin.  During  the  excision  itwas  noted  that  this 
tumor  was  adherent  to  the  omentum.  With  the  naked  eye  one  could  see  in  it  a  cavity 
containing  several  drops  of  brownish  fluid.  Microscopic  examination  showed  that  this 
cavity  was  scantily  lined  with  epithelium.  There  were  tubular  growths  and  cavities, 
some  more  or  less  filled.  By  strong  magnification  one  could  see  that  the  canals  and 
spaces  were  lined  with  cylindric  epithelium.  At  other  points  the  cavities  contained  ex- 
foliated epithelium.  Around  the  glands  the  connective-tissue  cells,  here  and  there, 
were  star-like  and  contained  large  quantities  of  collagen,  suggesting  the  tissue  of  the 
umbilical  cord.  At  other  points  the  connective  tissue  surrounding  the  gland  cavities 
showed  inflammatory  changes.  The  tubules  were  dilated,  and  here  and  there  were 
seen  emigrated  leukocytes.  In  some  of  the  connective-tissue  cells  hemosiderin  was 
visible. 


ADENOMYOMA    OF    THE    UMBILICUS. 


381 


■ 
■ 

T                 ■     ■  ■- 

'  /.  "\ 

S£:"'i 

'  ..:a*'~- 

iv'd 

Fig.  173. — Dichotomous  Branching  of  a 
Gland  in  a  Small  Umbilical  Tumor. 
(Mintz,  Case  3.) 

The  histologic  picture  might  very  read- 
ily be  taken  for  that  of  an  adenomyoma.  In 
the  lower  part  the  gland  shows  dichotomous 
branching. 


[In  this  case  we  are  not  so  sure  of  the  exact  condition.  It  reminds  us  somewhat 
of  adenomyoma,  but  no  mention  is  made  of  muscle.  It  is  just  possible  that  the  cells 
surrounding  the  glands  were  not  inflammatory, 
but  represented  ordinary  stroma.  This,  however, 
is  doubtful.  The  chief  points  in  favor  of  adeno- 
myoma are  that  the  tumor  was  painful  during 
menstruation,  and  that  the  cavities  contained 
blood  or  brownish  fluid;  furthermore,  that  the 
patient  had  been  operated  upon  for  a  fibroid 
growth  eleven  months  before,  and  that,  on  his- 
tologic examination,  hemosiderin  was  noted  in 
the  stroma.— T.  S.  C] 

A  Small  Umbilical  Tumor  Con- 
taining Uterine  Glands.  —  Case  3 
(Mintz) . — The  patient  was  a  woman,  forty-five 
years  of  age.  Nine  months  before,  she  had 
noticed  a  hardening  at  the  umbilicus.  During 
the  first  four  months  the  tumor  remained  station- 
ary in  size,  but  later  it  grew  and  was  painful. 
Then  the  growth  ceased  and  the  pain  disap- 
peared. The  skin  was  adherent  to  the  tumor;  it  was  brownish  in  color  and  travers- 
ing it  were  slightly  dilated  veins.  The  tumor 
passed  in  a  cone-shaped  form  into  the  umbilicus. 

The  tumor  on  section  was  found  to  consist  of 
firm  scar  tissue  in  which  numerous  small  cysts  filled 
with  brownish  contents  were  noted. 

Microscopic  Examination. — The  connective- 
tissue  portion  of  the  skin  passes  directly  into  the 
connective  tissue  of  the  tumor.  This  consists  of 
parallel  and  irregular  connective-tissue  strands, 
here  and  there  showing  small-round-cell  infiltra- 
tion. With  the  low  power  one  sees  cavities  of 
various  sizes  filled  with  a  brownish,  pigmented 
fluid.  The  small,  round  and  tubular  cavities  are 
partly  arranged  in  groups,  partly  separated  from 
one  another  by  old  scar  tissue.  The  tubules  here 
and  there  show  dichotomous  branching  (Fig.  173). 
At  several  points  the  growth  is  seen  passing  in 
various  directions.  At  many  points  where  one 
group  of  unchanged  tubules  exists,  it  is  surrounded 
by  young  connective  tissue,  which  toward  the  per- 
iphery passes  off  into  the  old  fibrous  tissue  (Fig. 
174).  The  cavities  of  more  recent  formation  and 
the  tubules  are  lined  with  one  layer  of  cylindric 
epithelium.  In  the  more  widely  dilated  cavities 
the  epithelium  assumes  a  flattened  shape.  On  further  dilatation  the  epithelium  be- 
comes still  flatter  and  drops  off  into  the  cavities.  These  cavities  are  surrounded  by  con- 
nective tissue  (Fig.  175) ;  they  contain  detritus,  swollen  epithelium,  and  leukocytes. 


Fig.  174. — Uterine  Glands  in  an  Um- 
bilical Tumor.  (Mintz,  Case  3.) 
The  gland  grouping  in  the  picture  is 
similar  to  that  seen  in  a  typical  adeno- 
myoma of  the  uterus.  In  the  colony  of 
glands  near  the  center  of  the  picture  the 
glands  are  regularly  distributed  and  are 
surrounded  by  a  definite  stroma  which 
separates  them  from  the  matrix  of  the 
tumor.  The  chain  of  glands  in  the  left 
upper  corner  is  in  part  surrounded  by 
stroma,  but  some  of  its  glands  lie  in  direct 
contact  with  the  dense  surrounding  tis- 
sue. 


382  THE    UMBILICUS    AND    ITS    DISEASES. 

[Mintz's  various  figures  are  very  suggestive,  and  Fig.  174  could  very  readily  be 
used  by  us  to  demonstrate  an  adenomyoma  of  the  uterus  instead  of  adenomyoma 
of  the  umbilicus.  Here  we  have  cross-sections  of  glands  forming  a  definite  colony. 
This  area  is  surrounded  by  the  characteristic  stroma  of  the  mucosa.  Fig.  175  could 
be  used  to  picture  a  mild  grade  of  gland  hypertrophy  of  the  uterus.  Here  also  the 
gland  is  surrounded  by  the  characteristic  stroma  of  the  mucosa.  Although  no 
mention  is  made  of  muscle  being  found  in  this  growth,  the  glands  and  the  gland 
branchings  are  absolutely  identical  with  those  of  the  uterus.  In  my  case  of  adeno- 
myoma of  the  round  ligament*  connective  tissue  predominated,  and  there  is  no 
reason  why  in  some  of  these  cases  also  connective  tissue  should  not  take  the  upper 
hand  throughout. — T.  S.  C] 

On  p.  396  Mintz  gives  a  resume  of  his  three  cases.  They  developed  in  women 
in  middle  life  in  the  umbilical  tissue,  and  the  tumors  reached  the  size  of  hazelnuts. 
The  growth  at  first  was  slow,  but  suddenly  increased  after  the  lapse  of  several 

months.  Examination  of  the  tumors  showed 
that  they  were  painful.  There  was  an  ex- 
acerbation (congestion)  at  the  menstrual 
periods. 

In  all  three  cases  the  microscopic  picture 

showed  the  growth  of  tubular  glands  in  the 

. ;■: •"%„...  scar  tissue  of  the  umbilicus,  this  glandular 

,r         ./  .:      V  growth  being  accompanied  by  granulation 

tissue  reaction.    This  young  connective  tis- 
-y  sue  surrounded  the  tubular  glands,  sepa- 

rated them  from  one  another,  and  trans- 
formed   itself    gradually   into    connective 
-  •      --'        tissue. 

fig.  175.— Glaxd  htpehtropht  in  a  Small  um-  [This  is  the  characteristic  stroma  which 

bilical  tumor.    (Mint*,  Case  3.)  one  normany  fin(is  separating  the  uterine 

Near  the  center  of  the  field  is  a  gland  showing  ■,        _,      «                                  ,  •.                rr\    q     r^  "| 

hypertrophy.     Separating  it  from  the  surrounding  glanOS  IrOlTl  Olie  anotner.        1.  b.  U.J 

stroma  is  a  characteristic  stroma  which  stains  more  The   gland   tubules  showed  One  layer   of 

deeply  and  is  rich  in  cell  elements.     This  picture  i-      i    ■             -n      t                  i   •    i           i            ,1        ,     i 

could  be  used  very  readily  as  an  example  of  a  uter-  CylmdriC   epithelium,  which,  when  the  tub- 

ine  gland  in  the  muscle.  ules  dilated  into  cavities  under  the  influence 

of  the  secretion,  became  flattened.  Finally 
this  epithelium  disintegrated  and  dropped  into  the  cavities  which  contained  the  albu- 
minous bodies  and  leukocytes.  Mintz  thought  the  tumors  originated  from  remains 
of  the  omphalomesenteric  duct.  He  then  describes  an  instance  of  a  somewhat  similar 
growth  reported  by  von  Xoorden  in  the  Deutsche  Zeitschr.  f.  Chir.,  1901. f 

A  Small  Umbilical  Tumor  Containing  Uterine  M  u  - 
cosa.i- —  The  patient  was  fifty-four  years  of  age,  and  had  had  no  children.  She 
had  had  an  abdominal  operation  ten  years  before  on  account  of  some  uterine  trouble. 

*  Cullen,  Thomas  S.:  Adenomyoma  of  the  Round  Ligament.  Johns  Hopkins  Hosp.  Bull., 
May,  1896,  112.  Further  Remarks  on  Adenomyoma  of  the  Round  Ligament.  Johns  Hopkins 
Hosp.  Bull..  1898,  142. 

t  See  also  Herzenberg,  R.:  Ein  Beitrag  zum  wahren  Adenom  des  Xabels.  Deutsche  med. 
V\  oc-henschr.,  1909,  i,  889.  Herzenberg  evidently  describes  the  same  cases  as  those  reported  by 
Mintz. 

i  Ehrlich,  H.:  Primares  doppeLseitiges  Mammacarcinom  und  wahres  Xabeladenom  (Mintz). 
Aus  von  EiseLsberg's  Klinik,  Arch,  f .  klin.  Chir.,  1909,  lxxxix,  742. 


ADENOMYOMA    OF    THE    UMBILICUS. 


383 


Shortly  after  leaving  the  hospital  she  developed  a  tumor  in  each  breast,  which 
gradually  reached  the  size  of  an  apple.  They  caused  little  difficulty,  and  in  the 
course  of  a  year  did  not  increase  much  in  size.  Simultaneously  with  the  appearance 
of  the  tumors  in  the  breasts  the  umbilicus  was  pressed  upward  markedly  by  a 
tumor  the  size  of  a  hazelnut,  developing  at  that  point.  This  growth  had  remained 
stationary.  The  umbilicus  had  been  transformed  into  a  small  tumor  with  pigmented 
skin.  The  tumor  was  hard,  and  was  with  difficulty  pushed  over  the  underlying 
structures.  The  umbilical  growth  and  the  carcinomata  of  both  breasts  were  re- 
moved. (We  are  here  inter- 
ested chiefly  in  the  umbilical  .-.-„• 
tumor.)                                                                            .  s-£.y.?-)vv  •  H  ;v:       •  '•  • 

The  tumor  of  the  umbilicus  fV    ,..- ■.    .,:\,  '■  '•• .  >  i '"''•'"  v.  •''.'• 

was  3  cm.  in  diameter.     Ma-  v..    •'•>.  4'V:"--/ vv°     /"■ '  ■  ' '".-^k.  ■'.'■  "-.•         f'4 

croscopically,  it  consisted  of  a  '*  ..-     V/ vvv~... ,'.  .    /  .'  .  ' 

hard,  pure  white,  scar-like  tis-  ■      ':'!       ;      •■+  '■'.  ■  '■■'■•■. ■-■  ■.  "." 

sue  firmly  attached  to  the  skin.  ,'.'•.  '      '       !-.;•'•.      'v    ; 

Scattered  throughout  the  turn-  m.      '■'     ■-•../        ..■•'       .'';''  "'■...  \     .'..-.■ 

or  were  a  number  of  pin-head-  ,  v  •••   ..  .  •     ,      v.. 

sized  spaces  which  contained  a  %      . '."  '  '•  .<  '  v 

serosanguineous    fluid.      His-  V.      ' v .     ..;f    .;1:\:       ;  ;•'•'  .  , 

tologically,  the  chief  mass  con-  .  /'  '    '..';.'"•',       KP   >,  ''.■■■.' 

sisted  of  fibrous  tissue,  poor  in  ...    •  '•'.;  -    .   .    •  ..  "V-         (     -   ' 

nuclei  and  cell-elements.     The  OU      ;'••-}  •      ..."    "•      :;, 

skin  covering  the  tumor,  ex-  ...■'"■ . ;    .  ..:-■.• 

cept  that  it  showed  a  marked  -       ''.-'-  ^''^/'''{uH 

pigmentation  of  the  basal  layer, 
looked  normal.  The  connec- 
tive tissue  of  the  skin  passed 
directly  into  that  of  the  under- 
lying tumor.  In  the  tumor 
were  numerous  islands  of  loose 
connective  tissue  which  varied 
markedly  in  the  number  of 
their  nuclei;  and  inside  this 
were  epithelial  elements.  There 
were  two  definite  histologic  pic- 
tures. In  the  portion  lying  near  the  skin  (Fig.  176)  were  groups  of  closely  com- 
pressed and  tortuous  gland  loops  lined  with  large  cuboid  epithelial  cells  having 
small,  centrally  located  nuclei.  The  gland  lumina  and  the  basement  membrane  of 
the  tubal  glands  were  easily  recognizable.  Similar  glands  were  also  found  in  the 
connective  tissue.     They  were  undoubtedly  hypertrophic  sweat-glands. 

Predominating  in  the  central  portion  of  the  extirpated  tumor  was  a  second  kind 
of  epithelial  tissue  likewise  situated  in  the  loose  connective  tissue,  but  exceedingly 
rich  in  nuclei.  This  consisted  of  tubular  glands  with  high  cylindric  epithelium; 
cilia  and  goblet-cells  were  not  visible.  Through  the  fork-like  arrangement  of  the 
tubular  glands  there  had  originated  here  and  there  many  bay-like  spaces  which 
might  be  mistaken  for  papillary  formations  and  which  had  given  rise  to  cystic 
formations  due  to  the  presence  of  fluid.     Here  and  there  the  epithelium  of  the  cystic 


•V  Y 


Fig.  176. — A  Tumor  of  the  Umbilicus  Composed  Partly  of  Hy- 
pertrophic Sweat-glands.  (After  H.  Ehrlich.) 
The  glands  are  gathered  into  definite  groups,  reminding  one  of 
the  gland  arrangement  in  small  fibromata  of  the  breast.  The  indi- 
vidual glands  bear  a  marked  resemblance  to  ordinary  sweat-glands. 
Some  of  them  are  dilated.  Another  portion  of  the  tumor  consisted  of 
typical  uterine  mucosa  (see  Fig.  177). 


384  THE    UMBILICUS    AND    ITS    DISEASES. 

spaces  had  disappeared  or  become  flattened.  The  contents  of  the  cysts  were  hem- 
orrhagic or  showed  a  formless  detritus,  and  in  several  places  surrounding  the  cysts 
were  masses  of  blood-pigment.  Van  Gieson's  stain  failed  to  bring  out  any  smooth 
muscle  surrounding  the  epithelial  elements.  This  was  found  only  in  connection 
with  the  vessels  of  the  connective  tissue  and  there  not  abundantly. 

While  the  glands  first  described  are  without  doubt  hypertrophic  sweat-glands, 
the  glands  of  the  second  group  are,  on  account  of  their  character  and  their  epithe- 
lium, in  all  probability  derivatives  of  the  intestinal  tract.  Ehrlich  speaks  of  the 
growth  as  an  adenoma  of  the  umbilicus. 

[The  reader  will  note  that,  judging  from  Fig.  176,  there  is  no  doubt  that  the  first 
gland  elements  described  by  Ehrlich  are  sweat-glands  and  that  the  tumor  consisted 
of  sweat-glands.     Fig.  177,  however,  shows  everywhere,  that  the  second  variety  of 


¥         '  n 


S  ■-'/ 


UK 


Fig.  177. — Uterine  Mucosa  in  an  Umbilical  Tumor.     (After  H.  Ehrlich.) 
To  the  left  are  characteristic  uterine  glands,  a  few  of  them  dilated.     They  are  surrounded  by  a  definite  stroma  which 
separates  them  from  the  connective  tissue.     In  the  right  portion  of  the  picture  are  similar  glands,  the  majority  of  which 
have  become  dilated.     If  we  take  the  left  half  of  the  picture  only,  it  might  very  readily  pass  without  any  description 
for  a  representation  of  an  adenomyoma  of  the  uterus. 

glands  can  in  no  way  be  connected  with  remnants  of  the  intestinal  duct,  but  that 
we  have  here  typical  uterine  mucosa  enveloped  in  a  definite  stroma. 

The  cystic  spaces,  as  noted  in  the  text,  were  partly  filled  with  blood.  They  are 
nothing  more  than  glands  that  have  been  markedly  dilated  by  old  menstrual  fluid. 
This  is  one  of  the  cases  in  which  the  definite  uterine  character  of  the  mucosa  is 
clearly  evident. — T.  S.  C] 

A  Tumor  of  the  Umbilicus  Consisting  of  a  Cystade- 
noma  of  the  Sweat-glands  and  a  Cavernous  Angioma. 
(Eine  Geschwuht  d  e  s  N  a  b  e  1  s  .  Kombination  von  Cyst- 
adenom  d  e  r  Schweissdrusen  m  i  t  cavernosem  Angiom.) 
— Wullsfein*  says  that  in  the  literature  he  has  found  no  tumor  similar  to  the  one  he 
is  describing.  In  1891  a  specimen  was  sent  to  the  Gottingen  laboratory.  This  con- 
sisted of  an  umbilical  tumor  which  had  developed  in  the  course  of  three  years  and 

*  Wullstein,   L.:    Arb.   a.   d.  Path.  Inst,  in  Gottingen,  R.  Virchow,  zum  50.  Doctor-Jubi- 
laum,  1893,  245. 


ADENOMYOMA    OF    THE    UMBILICUS.  385 

was  attached  by  a  thin  pedicle,  which  had  not  been  completely  removed.  The 
pedicle  had  extended  into  the  abdominal  cavity.  The  physician  in  charge  had 
made  a  diagnosis  of  myxofibroma.  The  patient  was  a  sterile  woman  thirty-four 
years  of  age.  In  addition  to  the  umbilical  tumor,  another  growth  was  present  in  the 
pelvis.  This  was  the  size  of  a  fist,  was  connected  with  the  uterus,  and  had  spread 
out  diffusely  in  the  neighborhood  of  the  right  broad  ligament.  It  could  not  be 
regarded  as  an  exudate.  The  physician  was  interested  to  find  out  whether  there 
was  any  connection  between  the  two  tumors;  in  other  words,  whether  the  umbilical 
growth  was  a  metastasis.  Wullstein  examined  a  Muller's  fluid  specimen.  It  was 
everywhere  covered  with  skin.  It  had  a  semicircular  form  and  was  about  the  size 
of  a  thaler.  The  umbilicus  was  raised  1  cm.  above  the  surrounding  abdominal 
skin,  and  its  surface  showed  numerous  shallow  furrows.  The  umbilical  furrow  was 
recognized  as  an  irregular,  transverse  cleft,  which  divided  the  umbilicus  into  two 
unequal  portions,  it  becoming  deeper  and  deeper  in  the  middle  until  there  was  a 
depression  11  mm.  in  depth.  About  the  middle  of  the  under  surface  of  the  tumor 
was  a  cord  about  1  cm.  long,  hardly  as  thick  as  a  straw.  This  was  solid  and  com- 
posed of  connective  tissue.  The  tumor  itself  was  about  3  cm.  long  and  averaged 
1.5  cm.  in  thickness.  On  section  it  was  seen  that  the  umbilicus  was  everywhere 
covered  with  skin,  which  in  all  portions  was  thickened  and  markedly  pigmented. 
From  the  bottom  of  the  umbilical  depression  and  running  parallel  were  thick  bundles 
of  dense  connective  tissue.  The  tumor  consisted  of  numerous  dense,  hard,  glisten- 
ing connective-tissue  bundles,  which  enclosed  more  or  less  long  or  round  areas  of 
loose  tissue,  grayish  in  appearance,  and  in  the  interior  in  places  were  small  lumina. 
Subcutaneous  fat  was  absent.  In  the  vicinity  of  the  umbilical  scar  the  tissue  was 
sieve-like.  The  spaces  of  the  meshwork  were  filled  with  dark-brown  masses  about 
the  size  of  poppy-seeds.     The  meshwork  consisted  of  firm  connective  tissue. 

Microscopic  examination  of  a  section  from  the  middle  of  the  tumor  showed  that 
the  epidermis  was  thickened.  The  deepest  cells  of  the  stratum  mucosum  were 
granular,  and  contained  everywhere  brown  pigment.  Only  at  the  base  of  the 
umbilicus,  where  the  papillae  were  not  markedly  formed,  was  the  pigment  absent. 
Everywhere  in  the  corium  and  in  the  subcutis  were  numerous  mast  cells.  Hair  and 
sebaceous  glands  were  nowhere  to  be  found.  The  deeper  layers  of  the  skin  con- 
tained normally  formed  sweat-glands.  The  tumor  consisted  chiefly  of  a  connective- 
tissue  stroma  and  of  cavities  varying  in  size  and  form.  The  stroma,  which  in 
amount  predominated  over  the  alveolar  tissue,  was  composed  of  broad,  thick,  dense 
connective  tissue,  which  contained  a  few  cell-elements  with  spindle-shaped  nuclei. 
Only  around  the  spaces  there  was  present  a  connective  tissue  which  was  very  delicate 
and  whose  fibers  formed  a  network  partly  as  fine  bundles.  The  numerous  nuclei 
were  oval  and  frequently  almost  round.  Immediately  around  the  alveoli  the  con- 
nective-tissue threads  formed  a  thick  layer,  really  a  membrana  propria.  The  cavi- 
ties were  lined  with  cylindric  cells  placed  at  right  angles  to  the  basement-membrane. 
Their  height  was  not  always  in  proportion  to  the  size  of  the  cavity,  but  seemed  to 
depend  on  the  pressure  of  the  gland  contents.  In  a  few  places  the  tubules  were 
filled  with  epithelium.  The  gland  tubules  were  usually  cut  either  obliquely  or 
longitudinally.  The  gland  lumina  near  the  periphery  of  the  tumor  in  width 
resembled  normal  sweat-glands.  On  the  other  hand,  those  in  the  middle  of  the 
tumor  were  markedly  dilated  and  round;  in  the  latter  the  tissue  was  frequently 
infiltrated  with  cells.  The  majority  of  the  glands  were  filled  with  a  secretion  com- 
26 


386  THE    UMBILICUS    AND    ITS    DISEASES. 

posed  of  a  most  delicate,  rather  granular  network  of  threads  mixed  with  epithelial 
cells.  The  entire  tumor  was  permeated  by  a  thick  network  of  capillaries  which  sur- 
rounded the  individual  gland  tubules.  In  many  places  in  the  connective-tissue 
stroma  in  the  neighborhood  of  the  blood-vessels  were  remnants  of  old  and  fresh 
blood. 

In  the  preparations  taken  from  the  lateral  portion  of  the  tumor  accumulations 
of  round  cells  and  blood-vessels  were  seen.  The  cystic  dilatation  of  the  canals  had 
evidently  been  produced  by  pressure  from  within.  The  cavities  were  lined  with 
endothelium,  and  the  walls  of  these  new  cavities  had  projections  into  them.  These 
cavities  were  due  to  the  confluence  of  the  neighboring  small  cavities.  The  origin 
of  these  in  some  places  could  be  followed.  At  several  points  between  the  blood- 
spaces  were  dilated  tubules  lined  with  cylindric  epithelium,  usually  filled  with 
secretion,  and  surrounded  by  the  characteristic  connective  tissue  which  sometimes 
reached  as  far  as  the  endothelium  of  the  blood-spaces.  A  few  of  the  gland-like 
cavities  also  contained  blood.     At  no  point,  however,  was  this  adherent. 

After  these  findings  we  must  ask:  Are  we  dealing  here  with  an  individual  tumor 
or  is  there  a  combination  of  two  tumors?  Further,  under  what  category  does  this 
tumor  formation  belong?  Wullstein  held  it  to  be  a  combination  of  cystadenoma  of 
the  sweat-glands  with  cavernous  angioma. 

On  p.  250  he  says  that  what  makes  him  think  there  is  a  combination  of  two 
tumors  is  the  fact  that  there  is  a  different  lining  to  the  large  spaces,  the  one  being 
lined  with  endothelium  and  the  other  with  cylindric  epithelium.  No  less  typical 
is  the  relation  of  the  surrounding  connective  tissue  to  the  spaces.  The  differences 
even  with  the  low  power  are  easily  recognized,  through  the  various  microchemical 
reactions  in  color  with  methylene-blue.  The  above  already  described  delicate 
bluish  connective  tissue  is  independent  of  the  sweat-glands  and  their  tributaries  in 
the  specimen,  and  is  present  only  in  the  vicinity  of  the  tubules  lined  with  cylindric 
epithelium,  whereas  the  spaces  lined  with  endothelium  are  always  surrounded  by 
a  thick,  fibrillated  tissue  which  stains  intensely  red.  He  thinks  that  the  large 
cavernous  spaces  in  the  first  place  are  due  to  circulatory  disturbances. 

On  p.  251  he  says  we  must  look  upon  the  sweat-glands  as  the  point  of  origin  for 
the  epithelium  of  the  new-growth,  on  account  of  the  position  of  the  tumor  beneath 
the  skin,  the  presence  of  cylindric  epithelium,  and  the  absence  of  squamous  epi- 
thelial nests.  Its  origin  from  the  epidermis  or  from  the  hair-follicles  or  the  sebaceous 
glands  is  excluded.  On  the  other  hand,  we  must  ask  whether  it  may  not  be  due 
to  some  embryologic  deposit.  Three  things  have  to  be  thought  of:  the  umbilical 
canal,  the  urachus,  and  the  omphalomesenteric  duct.  Have  we  in  this  mixed  tumor 
a  purely  accidental  combination  of  an  adenomatous  cyst  of  the  sweat-glands  and  a 
cavernous  angioma?  or  do  the  two  varieties  bear  a  causal  relation  one  to  the  other? 
In  conclusion,  he  says,  the  old  and  fresh  hemorrhages  in  various  portions  of  the 
tumor  have  followed  as  a  result  of  hyperemia — perhaps  the  menstrual  hyperemia. 
[Wullstein's  tumor  also  occurred  in  a  woman.  He  speaks  of  its  characteristic 
connective  tissue  separating  the  glands  lined  with  cylindric  epithelium  from  the 
surrounding  stroma.  Further,  in  his  last  paragraph  he  speaks  of  the  hemorrhage 
through  the  tumor  being  due  to  hyperemia,  possibly  menstrual  in  origin.  We 
believe  that  here  he  has  the  clue  and  that,  in  all  probability,  the  glands  in  this  case 
were  also  uterine  glands.  Although  the  description  of  the  histologic  appearances 
in  this  case  is  in  places  somewhat  involved,  we  have  in  our  translation  held  closely 


ADENOMYOMA    OF    THE    UMBILICUS.  387 

to  the  text  in  order  that  the  points  favoring  the  uterine  origin  of  the  glands  might 
not  be  unduly  accentuated.  I  wrote  Professor  Orth,  of  Berlin,  and  he  in  turn 
referred  me  to  Dr.  Wullstein,  who  at  the  time  this  case  was  published  (1893)  was  an 
assistant  of  Professor  Orth  and  occupied  the  room  next  to  mine  in  the  Gcittingen 
Laboratory.  Dr.  Wullstein  kindly  sent  me  the  reprint  of  his  article,  but  I  was  unable 
to  get  the  specimen,  and  consequently  cannot  speak  with  absolute  certainty.— 
T.  S.  C] 

N.  Giannettasio,  in  an  article,*  gives  a  resume  of  the  literature  on  tumors  of  the 
umbilicus,  and  reports  a  case  in  a  multipara  aged  forty-four.  A  year  and  a  half 
before  she  came  under  his  observation  the  patient  noticed  a  small  tumor  the  size 
of  a  walnut  at  the  umbilicus.  This  was  solid,  immobile  beneath  the  skin,  and  occa- 
sionedno  discomfort.  It  occupied  the  lower  andleft  side  of  the  umbilical  depression. 
It  was  removed,  and  the  patient  was  perfectly  well  twenty-five  months  later.  He 
gives  a  very  good  plate,  but  the  text  is  not  satisfactory.  The  nodule,  however,  he 
says,  contained  "cytogenous"  connective  tissue.  The  plate  shows  normal  skin, 
dilated  blood-vessels,  and  gland-spaces  lined  with  apparently  cuboid  epithelium, 
and  surrounded  by  a  stroma,  the  picture  somewhat  suggesting  uterine  glands. 

Probably  Uterine  Glands  in  a  Small  Umbilical  Tumor, f 
—  In  the  beginning  of  his  article  von  Noorden  states  that  he  is  going  to  demon- 
strate a  tumor  which,  from  its  characteristics  and  anatomic  picture,  leaves  no  doubt 
that  it  originated  from  the  sweat-glands,  and  that,  so  far  as  he  knew,  no  similar 
case  was  on  record.  On  October  1,  1898,  a  thirty-eight-year-old  multipara  told 
him  that  for  two  months  she  had  had  a  slight  unevenness  in  the  middle  of  the 
umbilicus.  Eight  days  previously  a  physician  had  observed  a  pea-sized  enlarge- 
ment in  the  floor  of  the  umbilicus.  Clinically  it  suggested  a  nevus,  and  on  account 
of  the  dark  pigmentation  von  Noorden  thought  of  melanosarcoma.  On  October 
14,  1898,  the  tumor  was  larger  than  a  pea,  semicircular,  and  not  sharply  defined  from 
the  surrounding  umbilical  tissue.  In  its  center  it  had  a  small,  wart-like  elevation. 
There  were  no  inflammatory  changes  in  the  vicinity.  The  skin  over  the  tumor  was 
somewhat  uneven,  grayish  in  color,  and  here  and  there  more  deeply  pigmented  than 
the  floor  of  the  umbilicus.  No  pulsation  was  noted,  no  variation  on  pressure.  The 
umbilicus  was  removed.     Two  and  a  half  years  later  the  patient  was  perfectly  well. 

The  umbilicus  on  section  showed  a  drawing  in  of  the  skin,  and  in  the  depth  there 
was  a  wart-like  projection.  The  tissue  of  the  umbilicus  itself  was  very  hard.  On 
section  a  pea-sized,  light  brownish,  pigmented  area  was  observed,  which  was  not 
sharply  defined  from  the  surrounding  tissue. 

Microscopic  Examination. — The  nodule  was  made  up  of  a  loose  connective 
tissue  with  numerous  large  cells.  It  contained  a  large  number  of  capillaries. 
Within  this  connective  tissue  were  slit-shaped  cavities  lined  with  cylindric  epi- 
thelium which  had  become  loosened  irregularly  from  the  wall.  Some  of  these 
cavities  had  become  dilated  into  irregular  cystic  spaces,  which  here  and  there  showed 
clearly  a  lining  of  cylindric  epithelium,  while  in  other  places  they  had  completely 
lost  it.  The  contents  of  these  cavities  had  dropped  out  in  some  places;  in  others  it 
consisted  of  cylindric  epithelium,  and  in  numerous  cases  of  an  irregular,  structure- 
less network.     Further  sections  were  made,  and  the  squamous  epithelial  layer  over 

*  Giannettasio,  N. :  Sur  les  tumeurs  de  l'ombilic.     Arch.  gen.  de  nied.,  1900,  n.  ser.,  iii,  52. 
t  von  Noorden,  W. :   Ein  Schweissdrusenadenom  mit  Sitz  im  Nabel  und  ein  Beitrag  zu  den 
Nabelgeschwtilsten.     Deutsche  Zeitschr.  f.  Chir.,  1901,  lix,  215. 


388  THE    UMBILICUS    AND    ITS    DISEASES. 

the  entire  nodule  was  found  to  be  intact.  Over  the  most  prominent  part  it  was 
three  times  as  thick  as  at  the  periphery.  Where  the  cells  were  most  abundant, 
the  deepest  layers  showed  pigmentation.  At  one  point  (Fig.  178)  "the  sweat- 
glands  ' '  could  be  traced  almost  to  the  surface,  being  covered  only  with  a  few  layers 
of  cells. 

The  stroma  consisted  of  three  definite  kinds  of  tissue :  normal,  dense  fibrous,  and 
mucoid-like  tissue.  The  chief  interest  lay  in  the  sweat-glands ;  roots  of  hairs  were 
nowhere  to  be  found,  and  sebaceous  glands  were  reduced  to  a  minimum.  The 
search  for  muscle-fibers  in  the  reticulate.d  tissue  was  fruitless.  No  elastic  fibers 
were  found. 

In  general  it  ma}^  be  said  the  sweat-glands  were  normal  in  the  subcutaneous 
layer  and  were  arranged  in  groups.  Then  in  one  section  one  would  find  two  large 
openings  and  three  or  four  glands,  and  in  another  section  groups  of  from  two  to 
four  glands.     Some  were  cut  in  such  a  manner  that  9  to  15  round  lumina  were  in  a 


*lw 


Fig.  178. — A  Small  Umbilical  Tumor  Containing  Numerous  Glands.     (After  von  Noorden.) 
This  is  a  low-power  picture  of  the  mass.     The  growth  is  covered  with  squamous  epithelium.     Scattered  through- 
out the  stroma  are  quantities  of  glands.     In  form  they  bear  a  closer  resemblance  to  uterine  glands  than  to  sweat-glands. 
At  one  point  the  glands  almost  reach  the  surface.      (For  a  higher  magnification  see  Fig.  179.) 

line  or  in  the  form  of  a  hook.  The  groups  lay,  as  a  rule,  very  close  to  one  another. 
The  normal  sweat-glands  lay  partly  in  the  fibrous  connective  tissue,  others — and  this 
is  to  be  noted — were  separated  by  a  rather  broad  layer  of  cells  from  the  normal 
corium.  The  nuclei  of  this  zone  were  pale  and  less  abundant  than  in  the  remaining 
corium.  This  zone  suggested  the  above-mentioned  mucoid  tissue,  in  which  in  part 
the  altered  glands  lay.  This  tissue  appeared  always  to  penetrate  between  the 
normal  gland  grouping,  and  had  separated  the  glands  from  one  another.  The  gland 
epithelium  was  not  changed.  In  addition  to  this  slightly  normal  and  slightly 
changed  skein-like  gland  there  were  in  the  corium  a  number  of  cavities  and  tubules. 
These  extended  from  near  the  surface  of  the  papillary  masses  to  the  vicinity  of  the 
subcutaneous  fat.  The  cavities  and  the  tubules  are  to  be  seen  in  Figs.  178  and  179. 
[We  do  not  clearly  understand  what  von  Noorden  means  by  corium.  It  seems, 
however,  that  he  uses  the  term  instead  of  stroma.  His  general  description  is  some- 
what hazy  throughout. — T.  S.  C] 


ADENOMYOMA    OF    THE    UMBILICUS. 


389 


On  p.  222  he  gives  a  resume  of  his  description:  The  tumor  is  made  up  of  many 
roundish  and  often  dilated,  cyst-like  portions  which  lie  deeply  seated  in  the  corium. 
In  intimate  relation  to  these,  or  independent  of  them,  are  tubular  channels  with 
numerous  corkscrew-like  windings.  These  extend  toward  the  epidermis.  The 
cystic  and  also  the  tubular  pictures  are  surrounded  by  dense  and  loose  connective 
tissue  which  separates  them  from  the  surrounding  connective  tissue  and  are  without 
any  definite  capsule.  In  the  above-described  coil  we  can  with  certainty  recognize 
the  sweat-glands. 

On  p.  229  he  reports  one  of  Mintz's  cases  and  says  that  possibly  the  new-growth 
had  developed  from  the  glandular  portion  of  the  skin;  for  example,  from  the  sweat- 
glands.  He  says:  "I  will  also  not 
assume  this,  but  will  say  that  portions 
of  my  tumor  in  respect  to  form,  group- 
ing, contents,  and  relation  of  the  cells, 
both  in  the  description  and  in  the  pic- 
ture, produce  a  very  similar  appear- 
ance to  the  case  reported  by  Mintz, 
and  had  it  not  been  possible  to  estab- 
lish a  relation  to  the  sweat-glands  I 
should  in  all  probability  have  followed 
the  views  of  Mintz.  Mintz  found 
smooth  muscle-fibers  in  the  connec- 
tive tissue  at  several  points.  The  ex- 
planation as  to  the  origin  is  difficult. " 
In  conclusion,  von  Noorden  says: 
"From  the  above  findings  a  true 
benign  adenoma  springing  from  the 
sweat-glands  can  be  diagnosed." 

[As  will  be  noted  from  the  history, 
the  patient  was  a  woman  thirty-eight 
years  of  age.  There  was  no  evidence 
of  inflammation.  Histologic  exam- 
ination in  some  places  showed  groups 
of  glands  lying  in  a  stroma  differing 
from  the  ordinary  surrounding  stroma. 
These  groups  of  glands  were  lined  with 
one  layer  of  cylindric  epithelium,  and 
the  cavities  of  some  of  the  dilated 

spaces  contained  cells  that  had  taken  up  blood-pigment.  Yon  Noorden  draws  at- 
tention to  the  fact  that  his  case  bore  a  marked  resemblance  in  many  ways  to  Mintz's 
case.  There  remains  little  doubt  in  my  mind  that  the  glands  resemble  those  found 
in  the  body  of  the  uterus,  and  the  thickened,  dense  stroma  around  them  bears  a 
marked  resemblance,  even  with  the  very  low  power,  to  the  stroma  of  the  uterine 
mucosa.  The  picture,  at  any  rate,  is  much  more  suggestive  of  a  glandular  growth 
of  uterine  origin  than  of  one  coming  from  the  sweat-glands.  I  endeavored,  through 
Professor  Doderlein,  of  Munich,  to  locate  Dr.  von  Noorden,  and,  if  possible,  secure 
a  section  of  this  growth,  but  have  not  been  successful. — T.  S.  C] 


"  §  •■ 

,     ■                       ■•■;  '      ""        *:    -V; 

W-3 

,-~    -       >  S**  :  ' 

"  X  -       -     ,-", 

■' :.'  i* 

iff  s    ,^]i 

—  ■   J&  i' 

7~-'   *'        ;             '-    | 

■■i  .X\:'&     ■      % 

Fig.  179. 


(After 


Glands  in  a  Small  Umbilical  Tumor. 
von  Noorden.) 
.  The  glands  in  the  lower  half  of  the  picture  bear 
quite  a  resemblance  to  uterine  glands.  Those  in  the  center 
of  the  field  remind  one  of  the  pictures  seen  in  the  depths  of 
uterine  glands,  where  there  is  some  reduplication  of  the 
folds.  The  gland  in  the  left  part  of  the  field  is  markedly 
dilated  and  contains  much  detritus. 


390  THE    UMBILICLTS    AND    ITS    DISEASES. 

It  is  rather  difficult  to  classify  this  tumor  reported  by  Villar,  but  as  it  presents 
a  few  clinical  and  histologic  points  suggestive  of  the  group  under  consideration,  I 
mention  it  here,  although  it  is  not  considered  in  the  digest.* 

L.  L..  aged  forty-six.  entered  the  service  of  Professor  Guyon  September  17, 1886. 
In  the  month  of  December,  1885,  nothing  abnormal  was  noticed  in  the  umbilical 
region,  but  shortly  afterward  her  corsets  produced  pain  in  this  region  and  she  dis- 
covered a  small  tumor  the  size  of  a  pin-head,  reddish  in  color,  in  the  umbilical 
depression.  This  tumor  increased  very  slowly,  and  in  May,  1886,  she  went  to  the 
hospital  for  examination.  She  continued  under  treatment,  and  in  the  month  of 
August  entered  the  hospital.  At  that  time  at  the  umbilical  depression  was  a  tumor 
the  size  of  a  bird's  egg.  It  was  conic.  Its  base  was  continuous  with  the  cicatrix, 
and  was  somewhat  constricted  by  the  depression.  It  had  a  very  narrow,  but 
relatively  large  pedicle.  It  was  in  reality  sessile,  firm  in  consistence,  but  elastic 
and  reddish  in  color.  At  the  top  was  a  blackish  point,  2  mm.  in  diameter.  The 
tumor  itself  was  not  ulcerated  and  did  not  discharge  any  liquid.  Two  or  three  days 
after  she  entered  the  hospital  the  blackish  point  ruptured  and  there  was  an  escape 
of  tarry  blood.  The  patient  experienced  no  pain  and  there  was  no  glandular  enlarge- 
ment. 

Histologic  Examination  by  Clado. — The  tumor  is  situated  in  the  center  of  the 
umbilicus  and  has  developed  in  the  depth  of  the  cicatrix.  It  is  covered  with  skin. 
In  consistence  it  is  a  little  less  firm  than  a  fibroma.  On  section  one  finds  a  capsule 
which  surrounds  the  central  mass.  The  tumor  is  whitish-gray,  with  numerous  dark 
spots  not  any  larger  than  the  head  of  a  pin  scattered  throughout  it.  Microscopic 
examination  shows  that  the  tumor  is  formed  of  sarcomatous  tissue,  the  cells  being 
fusiform  in  shape. 

Some  of  the  spaces  are  round,  others  oval,  and  have  anastomosed  with  one 
another.  Some  of  the  canals  are  lined  with  pavement  epithelium.  Between  the 
cystic  spaces  one  finds  stroma  containing  a  small  number  of  vessels.  The  skin 
which  composes  the  outer  covering  of  the  tumor  is  exceedingly  thin,  but  presents 
the  characteristic  appearance.  There  has  been  extravasation  of  blood  at  the  center 
of  the  tumor. 

[This  woman,  as  above  noted,  was  fortj^-six  years  of  age.  The  history  does  not 
convince  one  absolutely  that  this  was  a  sarcoma.  It  might  very  well  have  been 
a  fibroma.  It  resembles  in  a  few  particulars  those  tumors  of  the  umbilicus  that 
contain  uterine  glands  or  glands  somewhat  resembling  them. — T.  S.  C] 

Further  Cases  of  Adenomyoma  of  the  Umbilicus. 
These  four  cases  have  come  to  my  knowledge  since  this  chapter  was  prepared. 

They  bear  a  striking  resemblance  to   those   already  discussed  in  the  preceding 

pages : 

T  w  o  U  in  b  i  1  i  c  a  1   T  u  in  o  r  s   of   Probable   Uterine   O  r  i  g  i  n  .  f 
"  In  the  surgical  service  of  Drs.  Munro  and  Bottomley,  at  the  Carney  Hospital, 

there  recently  occurred  within  a  few  weeks  of  each  other  two  examples  of  umbilical 

tumor,  the  striking  similarity  and  unusual  histologic  structure  of  which  warrant 

their  publication. 

*  Villar:  Tumours  de  l'ombilie.     These  de  Paris,  1886,  obs.  68. 

t  ( roddard,  Samuel  W.\  Surg.,  Gyn.  and  Obst,,  August,  1909,  249-252. 


ADENOMYOMA    OF    THE    UMBILICUS.  391 

"Because  of  the  comparative  rarity  of  these  cases  the  clinical  histories  are  set 
forth  in  considerable  detail : 

"Case  1. — Miss  S.,  a  housekeeper,  forty-four  years  of  age,  and  born  in  New 
Brunswick,  entered  the  Carney  Hospital  May  22,  1907.  Her  family  and  past  history 
have  no  bearing  on  her  condition  at  that  time.  A  year  previously,  during  a  cata- 
menial  period,  she  noted  some  redness  and  tenderness  about  the  umbilicus;  two 
months  later,  at  a  similar  time,  a  small  tumor  appeared  in  the  abdominal  wall  close 
to  the  umbilicus.  This  tumor  increased  in  size  but  slightly,  and  most  of  the  increase 
came  in  the  two  weeks  just  preceding  her  admission  to  the  hospital.  The  tender- 
ness and  pain,  which  at  first  were  evident  only  during  the  menstrual  periods,  had 
been  constant  for  some  months,  though  most  marked  just  before,  during,  and  for  a 
week  after  menstruation.  Her  menstrual  history  wras  not  otherwise  remarkable. 
An  abdominal  bandage,  her  only  treatment,  had  given  her  some  relief.  There  had 
been  some  little  loss  of  weight  and  strength.  For  two  months  the  tenderness  had 
kept  her  from  her  usual  work.  No  symptoms  referable  either  to  the  gastro-intestinal 
or  to  the  urinary  tract  had  been  noted. 

"About  and  including  the  umbilicus  was  a  rather  deep-seated,  spheric,  slightly 
tender,  fixed  mass,  of  rather  firm  consistence,  and  about  2  cm.  in  diameter.  In  the 
navel  itself  was  a  thin,  yellowish  crust;  a  sinus  could  not  be  demonstrated;  the 
skin  over  the  tumor  was  not  red.  Examination  of  the  abdomen  was  otherwise 
negative.  Examination  per  vaginam  showed  only  vaginismus  and  a  moderately 
retroverted  uterus. 

"On  May  23d  Dr.  Munro  excised  the  growth  (including  the  navel)  with  a  portion 
of  the  adjacent  peritoneum  and  sheath  of  the  rectus  muscle.  The  former  was  not 
involved  in  the  growth;  to  the  latter  the  growth  was  adherent.  The  convalescence 
was  without  note,  and  the  patient  was  still  free  from  recurrence  one  year  after  opera- 
tion. 

"Case  2. — Mrs.  D.,  a  housewife,  entered  the  Carney  Hospital  June  23,  1907. 
She  was  born  in  Ireland  forty-two  years  before  that  time,  and  came  of  healthy  stock. 
Her  menstrual  history  previous  to  her  marriage  was  entirely  normal  in  every  way. 
Married  seventeen  years,  she  had  borne  four  children.  Following  her  first  confine- 
ment she  had  had  a  '  milk  leg. ' 

"For  six  years  previous  to  entering  the  hospital  a  slight  bloody  discharge 
from  the  navel  without  pain  or  tenderness  had  come  with  each  menstruation.  The 
discharge  came  only  at  that  time.  Independent  of  the  umbilical  disorder  she  had 
had  in  the  past  three  years  attacks  of  sharp  pain  beneath  the  right  costal  border, 
accompanied  by  vomiting,  chills,  and  jaundice. 

"The  patient  was  rather  obese,  and  showed  distinct  tenderness  beneath  the 
right  costal  border.  At  the  umbilicus  was  a  small,  irregularly  shaped  papillo- 
matous tumor,  2  cm.  in  diameter,  with  three  distinct  projections  covered  with 
normal  appearing  skin.  At  the  top  of  the  largest  projection  was  a  pin-hole  open- 
ing capped  with  dried  blood.  The  tumor  was  soft,  freely  movable,  not  tender,  and 
apparently  superficial. 

"On  June  24th  the  umbilicus  with  the  tumor  was  excised  by  Dr.  Bottomley. 
The  tumor  was  confined  to  the  skin  and  fat  outside  the  aponeurosis.  The  peri- 
toneal cavity  was  opened,  and  the  gall-bladder  and  stomach  regions  were  explored; 
these  were  found  normal.  Convalescence  was  uneventful  except  for  the  develop- 
ment of  malaria  on  the  ninth  day,  which  promptly  yielded  to  treatment.     The 


392  THE    UMBILICUS    AND    ITS    DISEASES. 

patient  was  discharged,  relieved,  on  July  11th,  and  when  heard  from,  one  and  a 
half  3rears  later,  there  had  been  no  recurrence. 

"For  the  microscopic  study  of  these  tumors,  in  the  laboratory  of  Dr.  Henry 
A.  Christian  at  the  Harvard  Medical  School,  a  large  number  of  sections  were 
taken  from  different  planes  and  four  different  methods  of  staining  were  used  for 
each  section. 

"So  closely  do  the  tumors  resemble  each  other  microscopically  that  no  evident 
difference  between  them  can  be  determined.  The  arrangement  and  construction, 
both  in  general  and  particular,  are  nearly  identical.  For  descriptive  purposes  a 
median  longitudinal  section  of  Case  2  will  be  used.  To  the  naked  eye  it  presents 
an  irregularly  convex  surface  covered  with  true  skin.  Underlying  this  at  each 
extremity  are  what  appear  to  be  sweat-glands,  and  in  another  part,  chiefly  in  the 
center,  are  numerous  vacuolated  structures  varying  in  size  from  a  pin-point  to  a 
pin-head.  The  intervening  structure  cannot  be  definitely  determined.  Micro- 
scopically, the  tumor  is  seen  to  be  covered  with  normal  epidermis,  but  varying  in 
thickness.  Below  this,  at  either  end,  are  numerous  sweat-glands,  thickly  grouped, 
and  around  these  is  an  abundance  of  fibrous  connective  tissue.  The  vacuolated 
or  glandular  structures  found  throughout  the  tumor  vary  in  size,  and  for  the  most 
part  are  of  rounded  contour,  while  some  are  elongated.  Some,  especially  the  larger 
ones,  are  discrete,  while  others  are  aggregated  into  small  groups.  Some  are  imme- 
diately surrounded  by  fibrous  tissue,  while  others  are  embedded  in  cellular  tissue. 
There  are  none  which  appear  to  have  any  connection  with  the  epidermis.  All  the 
gland-spaces  are  lined  with  epithelium.  They  are  either  devoid  of  contents,  or  con- 
tain a  granular,  structureless  material  in  which  are  often  found  groups  of  red  blood- 
cells.  The  epithelium  varies  in  the  different  glands  and  even  in  the  same  gland, 
from  the  low,  flattened  variety  to  the  tall,  columnar  cells  with  all  the  intermediate 
forms.  The  tall,  columnar  variety  is  for  the  most  part  closely  compacted,  with 
long,  narrow  nuclei  and  with  no  visible  cell  membrane.  Most  of  them  have  a  dis- 
tinct top  plate,  and  many  show  cilia  of  considerable  length  and  uniformity,  while 
others  have  only  a  suggestion  of  striae.  The  cilia  in  some  places  are  from  one- 
fourth  to  one-third  the  length  of  their  cells,  and  in  others  their  extremities  end  in  a 
globular,  deeply  staining  tip.  At  irregular  intervals  among  the  nuclei  of  the  col- 
umnar cells  are  larger  rounded  and  more  faintly  stained  nuclei.  In  some  places 
the  epithelium  is  distinctly  cuboid,  the  nuclei  clear  and  rounded,  and  the  whole 
cell  clearly  defined.  There  is  a  larger  group  of  glands  which  presents  the  flattened 
epithelium.  The  epithelium  lining  the  glands,  whether  flattened,  cuboid,  or  col- 
umnar, is  for  the  most  part  in  single  layers.  In  some  places  the  glandular  epithelium 
is  immediately  supported  by  fibrous  connective  tissue,  but  in  others  the  underlying 
structures  are  decidedly  cellular.  The  cellular  tissue  is  more  compact  the  nearer 
the  glandular  tissue  is  approached,  i.  e.,  the  most  cellular  tissue  is  found  in  close 
connection  with  the  gland-spaces.  The  nuclei  are  rounded  or  elongated  and  deeply 
stained,  the  protoplasm  and  cell  membrane  not  being  distinct.  In  the  immediate 
neighborhood  of  some  of  the  gland-spaces  are  large  hemorrhagic  areas  in  which  large 
quantities  of  red  blood-cells  are  scattered  freely  and  intermingled  with  the  cellular 
structures.  These  areas  seem  to  have  no  direct  relation  to  blood-vessels,  which 
are  not  superabundant  or  enlarged.  The  fibrous  connective  tissue  shows  nothing 
of  interest  throughout  the  section.  There  is  an  abundance  of  smooth  muscle  which 
is  closely  interwoven  with  the  connective  tissue." 


ADENOMYOMA    OF    THE    UMBILICUS.  393 

The  microphotographs  accompanying  Goddard's  article  bring  out  clearly  the 
structure  and  arrangement  of  the  tumors,  and  emphasize  the  points  mentioned 
above. 

Adenomyoma  of  the  Umbilicus;  also  a  S  m  all  Adeno- 
myoma  near  the  Anterior  Iliac  Spine.*  —  Case  3. — "A  woman, 
aged  thirty-seven,  came  to  me  on  September  2,  1908,  for  advice  about  a  small  tumor 
of  the  umbilicus  which  she  had  noticed  during  the  last  few  months.  The  lump  was 
about  the  size  of  a  filbert,  and  lay  in  the  lower  part  of  the  navel.  It  was  irregular 
in  outline,  but  smooth,  and  was  of  a  bluish-purple  color,  suggesting  a  melanotic 
sarcoma.  There  were  no  abdominal  symptoms  or  signs  and  no  secondary  deposits 
in  the  inguinal  glands  or  elsewhere.  A  few  days  later  I  removed  the  whole  navel 
and  adjacent  skin  widely  between  two  elliptic  incisions,  opening  the  abdomen  on 
either  side  and  taking  away  the  intervening  peritoneum.  There  were  no  traces  of 
growth  within  the  peritoneal  cavity.  The  wound  was  stitched  up  in  layers  and 
healed  absolutely  by  first  intention.  The  specimen  was  given  to  Air.  Lawrence, 
the  curator  of  our  museum,  for  examination.  Sections  showed  to  the  naked  eye 
a  hard,  fibrous  structure,  the  superficial  parts  of  which,  under  the  epithelial  cover- 
ing of  the  navel,  were  pigmented.  In  the  deeper  parts  of  this  fibrous  tissue  were 
many  islands  of  tubular  glands  lined  with  columnar  epithelium  and  filled  with 
epithelial  debris.  Some  were  cut  obliquely  and  showed  a  looser  areolar  investing 
layer  outside  the  membrana  propria.  The  latter  was  not  penetrated  by  the  cells, 
so  that  one  sign  of  the  benign  character  of  the  tumor  was  present.  Nor  were  there 
any  other  signs  of  the  spread  of  the  growth  beyond  the  limits  of  the  tubules.  L 
therefore,  put  it  down  as  an  adenoma  derived  from  remnants  of  the  vitelline  duct, 
of  which  I  had  read  but  never  seen. 

"I  saw  no  more  of  this  lady  until  January,  1913,  when  she  consulted  me  about  a 
little  nodule  seated  in  the  subcutaneous  fat,  about  two  inches  internal  to  the  left 
anterior  iliac  spine.  It  felt  about  the  size  of  a  pea,  and  was  hard.  On  gently  pinch- 
ing the  skin  the  latter  puckered  over  the  nodule.  There  were  no  enlarged  inguinal 
glands  or  other  signs  of  infiltration.  This  knot  was  removed  shortly  after  by  Mr. 
F.  Hinds,  of  Worthing,  and  was  sent  to  me.  Mr.  Lawrence  kindly  prepared  several 
microscopic  sections  of  it.  They  showed  precisely  the  same  structure  as  the  first 
nodule,  except  that  the  fibrous  tissue,  which  made  up  the  bulk  of  the  mass,  was  more 
dense  and  fewer  connective-tissue  corpuscles  were  scattered  through  it. 

"The  reappearance  of  this  small  knot,  repeating  the  structure  of  the  first  nodule 
at  the  umbilicus,  suggests,  of  course,  strongly  that  the  first  was  malignant  and  has 
recurred  in  the  lymphatics  of  the  subcutaneous  tissue  of  the  abdominal  wall.  Then 
the  question  arises,  Was  the  original  lump  in  the  umbilicus  a  primary  growth  in  some 
of  the  glandular  remnants  of  the  umbilicus  enumerated  above,  or  could  it  be  a 
nodule  secondary  to  some  visceral  carcinoma  within  the  abdomen?  This  latter 
view  is  one  adopted  by  Mr.  Shattock,  to  whom  I  sent  sections  of  both  the  first 
nodule  removed  and  that  obtained  four  and  a  half  years  later,  and  who  was  kind 
enough  to  write  to  me  fully  on  the  subject.  It  may  be  correct,  but  so  far  the  lady 
has  shown  no  evidence  of  visceral  trouble — nearly  five  years  after  the  appearance 
of  the  first  nodule  in  the  umbilicus.  Time  alone  will  show.  In  the  meanwhile  I  am 
inclined  to  negative  the  visceral  theory." 

*  Barker,  A.  E. :  Three  Cases  of  Solid  Tumours  of  the  Umbilicus  in  Adults.  The  Lancet, 
London,  July  19,  1913,  128. 


394  THE    UMBILICUS    AND    ITS    DISEASES. 

In  answer  to  a  request  from  me,  Dr.  Barker  very  kindly  sent  the  only  section 
of  the  umbilical  tumor  which  the  curator  of  the  museum  still  possessed. 

Description  of  the  slide  sent  me  by  Dr.  Barker  (His  No.  10,945). — The  section  of 
the  umbilical  nodule  has  a  normal  covering  of  squamous  epithelium.  The  underlying 
tissue  shows  no  evidence  of  glandular  tissue.  Dr.  Barker,  however,  in  his  descrip- 
tion of  the  case,  says  that  this  tumor  contained  glands,  and,  furthermore,  that  the 
glands  near  the  anterior-superior  spine  were  similar  in  character  to  those  found  at 
the  umbilicus.     Dr.  Barker  was  good  enough  to  also  send  me  several  slides  from 


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Fig.  ISO. — Adenomyoma  in  the  Abdominal  Wall  near  the  Anterior  Iliac  Spine. 
This  is  a  photomicrograph  of  a  portion  of  the  small  nodule  furnished  me  by  Mr.  Arthur  E.  Barker,  London,  Eng- 
land. Near  the  center  of  the  field  are  two  glands.  Their  epithelium  has  been  slightly  strengthened  to  bring  them  out 
more  distinctly.  The  glands  are  lined  with  one  layer  of  cylindric  epithelium.  Surrounding  them  is  a  zone  of  stroma 
cells.  This  zone  is  continuous  with  a  large,  irregular  area  of  stroma  just  below  and  to  the  left  of  the  glands.  In  the 
upper  part  of  the  field  is  another  gland,  which  lies  in  direct  contact  with  the  tissue  of  the  tumor.  The  greater  part  of 
the  nodule  consLsts  of  non-striped  muscle  and  fibrous  tissue.  In  the  outlying  portions  of  the  field  is  adipose  tissue. 
The  growth  is  a  typical  adenomyoma,  with  glands  similar  to  those  of  the  uterine  mucosa.  Mr.  Barker,  in  his  descrip- 
tion of  the  case,  says  that  the  umbilical  nodule  and  the  one  here  depicted  were  identical  in  character;  consequently  the 
umbilical  growth  was  also  an  adenomyoma  with  glands  and  stroma  identical  with  those  of  the  endometrium  of  the 
uterus. 

the  growth  near  the  anterior-superior  spine.  In  one  section  I  found  not  only 
myomatous  tissue,  but  a  triangular  area  of  stroma  with  tubular  glands  at  one  end 
Tig.  180;.  This  area  was  sharply  defined  from  the  surrounding  tissue.  In  another 
section  was  what  appeared  to  be  fibrous  tissue,  and  possibly  a  little  muscle.  Here 
we  had  irregular,  triangular  areas  of  stroma,  sometimes  without  any  glands,  some- 
times with  tubular  glands  identical  with  those  of  the  uterine  mucosa.  At  other 
points  the  glands  lay  in  direct  contact  with  the  muscle.  Surrounding  the  entire 
growth  was  adipose  tissue.     The  picture  in  the  main  is  analogous  to  that  which  we 


ADENOMYOMA    OF    THE    UMBILICUS.  395 

have  described  as  representing  adenomyoma  of  the  umbilicus.  Mr.  Barker's  case  is 
particularly  interesting  in  that  he  had  not  only  a  tumor  of  this  character  at  the 
umbilicus,  but  also  a  nodule  near  the  anterior  iliac  spine. 

A  Small  Umbilical  Tumor  Consisting  i  n  P  a  r  t  o  f  Sweat- 
glands  and  in  Part  Apparently  of  Uterine  Glands.- — 
While  in  Atlanta,  at  the  meeting  of  the  Southern  Surgical  Association  in  December, 
1913,  Dr.  Edward  G.  Jones,  of  Atlanta,  told  me  that  he  had  recently  seen  an  umbil- 
ical tumor  in  which  I  might  be  interested.  On  December  22,  1913,  he  wrote:  "I 
am  sending  under  separate  cover  a  section  of  the  umbilical  tumor.  Unfortunately, 
I  cannot  give  you  any  clinical  data.  The  nodule  was  three-quarters  of  an  inch  in 
diameter,  and  gave  the  patient  some  discomfort  at  times."  Later  Dr.  Jones  dis- 
covered that,  according  to  the  patient's  account,  the  tumor  seemed  to  her  to  enlarge 
at  the  time  of  menstruation. 

The  specimen  sent  me  by  Dr.  Jones  is  covered  over  with  squamous  epithelium 
which  contains  pigment  in  the  deeper  layers.  The  underlying  tissue  consists  in  a 
large  measure  of  fibrous  tissue.  The  capillaries  scattered  throughout  it  are  in  many 
places  surrounded  by  round  cells.  Here  and  there  throughout  the  fibrous  tissue 
are  groups  of  sweat-glands.  These  are  separated  from  the  fibrous  tissue  by  a  defi- 
nite stroma. 

At  other  points  are  large  glands  lined  with  cylindric  epithelium.  Some  of  these 
glands  lie  in  direct  contact  with  the  fibrous  tissue;  others  have  a  definite  stroma, 
separating  them  from  the  connective  tissue.  This  stroma  stains  more  deeply  than 
the  connective  tissue,  and  its  nuclei  are  oval  and  stain  deeply. 

The  tumor  is  evidently  made  up  of  two  distinct  varieties  of  glands:  some  cor- 
responding to  sweat-glands  and  others  bearing  a  marked  resemblance  to  those  of  the 
uterine  mucosa.  There  is  little  doubt  that  part  of  this  growth  consists  of  uterine 
glands.  The  section  was,  unfortunately,  too  thick  to  supply  a  satisfactory  photo- 
micrograph. 

PERSONAL  OBSERVATION. 

In  1900  Mrs.  E.  J.  D.,  aged  thirty-eight,  was  admitted  to  Dr.  Howard  A.  Kelly's 
Sanitarium  on  account  of  a  retroflexed  uterus  and  a  relaxed  vaginal  outlet.  A  small 
round  nodule  was  at  the  same  time  detected  at  the  umbilicus.  The  nodule  was 
removed,  the  uterus  brought  up  into  position,  and  the  perineum  repaired.  Her 
convalescence  was  prolonged  on  account  of  phlebitis  in  both  legs. 

This  patient  was  the  mother  of  four  children.  Her  menses  began  at  thirteen, 
were  fairly  regular,  and  lasted  from  three  to  five  days.  About  two  years  before 
admission  the  patient  first  felt  a  little  pain  in  the  umbilical  region.  During  the 
last  year  this  had  become  very  severe  and  the  small  umbilical  growth  had  developed. 
There  was  no  reddening  at  the  umbilicus,  and  the  general  health  had  not  been 
affected. 

This  small  umbilical  tumor  was  brought  over  to  the  gynecologic  laboratory  of 
the  Johns  Hopkins  Hospital  and  carefully  examined.  For  some  unforeseen  reason 
it  was  not  indexed,  and,  consequently,  when  we  were  getting  together  all  our  umbil- 
ical material,  was  overlooked.  It  was  accidentally  discovered  when  class  sections 
were  being  gone  over  a  few  days  ago  (March  3,  1915).  Dr.  Elizabeth  Hurdon,  who 
examined  the  specimen  at  the  time,  drew  special  attention  to  the  fact  that  the 


396 


THE    UMBILICUS    AND    ITS    DISEASES. 


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Fig.  is). — A  Small  Umbilical  Tumor  Containing  Glands  Similar  to  those  of  the  Body  of  the  Uterus. 

Gyn.-Path.  No.  X'.lll.  This  is  a  low-power  photomicrograph  of  a  section  of  the  entire  umbilical  nodule.  The  skin 
covering  is  normal.  Occupying  the  lower  half  of  the  field  is  a  somewhat  circular  growth,  denser  in  structure  than  the 
surrounding  stroma.  It  consisted  of  fibrous  tissue  and  non-striped  muscle.  Scattered  throughout  the  tumor  are 
glands.  Some  occur  singly,  others  in  groups.  Some  of  the  smaller  glands  are  surrounded  by  a  dark  zone — a  zone 
of  characteristic  stroma.  Many  of  the  glands  are  dilated  and  partially  filled  with  blood.  In  the  upper  part  of  the 
field  are  aggregations  of  sweat-glands.     (For  the  higher  power  picture  see  Figs.  182  and  183.) 


ADENOMYOMA    OF    THE    UMBILICUS. 


397 


glands  in  the  growth  were  similar  to  those  of  the  endometrium ,  and  that  some  of 
them  were  surrounded  by  the  characteristic  stroma  of  the  uterine  mucosa. 

Gvn.-Path.    No.    39  14.     The  tumor  averages   1.5  cm.   in  diameter. 


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Fig.  182. — Adenomyoma  of  the  Umbilicus. 
Gyn.-Path.  No.  3914.  This  picture  gives  an  enlargement  of  the  adenomyoma  seen  in  Fig.  181.  The  stroma  of  the 
growth  consists  of  non-striped  muscle  and  fibrous  tissue.  Occupying  the  center  of  the  field  are  several  glands.  They 
were  lined  with  one  layer  of  cylindric  epithelium,  on  which  cilia  were  here  and  there  demonstrable.  The  glands  are 
separated  from  the  muscle  by  a  definite  stroma.  This,  with  a  higher  power,  was  found  to  be  identical  with  that  of  the 
endometrium  of  the  uterus.  In  the  left  upper  corner  of  the  picture  is  a  markedly  dilated  gland.  This  and  other  dilated 
glands  contained  old  blood  and  exfoliated  epithelial  cells,  which  had  taken  up  blood-pigment  and  had  become  spheric. 
The  entire  picture  of  the  umbilical  tumor  is  analogous  to  that  of  an  adenomyoma  of  the  uterus. 

Its  outer  surface  is  covered  with  normal-appearing  skin.     On  section  it  presents 
a  dense  fibrous  structure. 

On  histologic  examination  the  skin  surface  is  found  intact  and  normal.  The 
stroma  of  the  growth  consists  of  fibrous  tissue  with  a  moderate  amount  of  non- 
striped  muscle  distributed  throughout  it. 


398 


THE    UMBILICUS    AND    ITS    DISEASES. 


Scattered  here  and  there  throughout  the  nodule  are  round  or  tortuous  glands. 
Some  of  these  occur  in  groups,  others  are  single  (Figs.  181  and  182).  The  glands  are 
lined  with  one  layer  of  low  cylindric  epithelium,  which  in  a  few  places  shows  defi- 
nite cilia.  Some  of  the  gland  cavities  are  empty,  others  are  dilated  and  filled  with 
old  blood,  and  in  a  few  are  exfoliated  epithelial  cells  which  have  become  spheric 
and  have  taken  up  the  blood-pigment.  Some  of  the  glands  lie  in  direct  contact 
with  the  muscle  or  fibrous  tissue;  others  are  separated  from  the  dense  tissue  by  a 


Fig.  183. — A  Group  of  Sweat-glands  in  an  Umbilical  Tumor. 
Gyn.-Path.  No.  3914.     For  their  relation  to  the  adenomyoma  of  the  umbilicus  see  Fig.  181. 


definite  stroma,  which  is  very  cellular.  The  picture  is  that  of  a  typical  adenomyoma 
with  glands  identical  with  those  of  the  uterine  mucosa. 

At  one  point  is  an  aggregation  of  glands  of  a  totally  different  type.  These 
glands  are  small,  round,  and  have  a  lining  of  two  layers  of  low  cuboid  cells.  They 
closely  resemble  sweat-glands  (Fig.  183). 

This  is  another  definite  example  of  an  adenomyoma  of  the  umbilicus.  It  will 
be  remembered  that  in  several  of  the  recorded  cases  the  sweat-glands  were  markedly 
increased  in  number. 


ADENOMYOMA    OF    THE    UMBILICUS.  399 


LITERATURE  CONSULTED  IN  THE  PREPARATION  OF  UMBILICAL  TUMORS  CON- 
TAINING UTERINE  MUCOSA  OR  REMNANTS  OF  MULLER'S  DUCT. 
Barker,  Arthur  E.:   Three  Cases  of  Solid  Tumours  of  the  Umbilicus  in  Adults.    Lancet,  London, 

July  19,  1913,  128. 
Cullen,  Thomas  S.:    Umbilical  Tumors  Containing  LTterine  Mucosa  or  Remnants  of  Midler's 

Ducts.     Surg.,  Gyn.  and  Obstet.,  May,  1912,  479. 
Ehrlich:    Primares  doppelseitiges  Mammacarcinom    und  wahres  Nabeladenom    (Mintz).    Aus 

von  Eiselsberg's  Klinik.     Arch,  f .  klin.  Chir.,  1909,  lxxxix,  742. 
Giannettasio :  Sur  les  tumeurs  de  l'ombilic.     Arch.  gen.  de  med.,  1900,  n.  serie,  iii,  52. 
Goddard,  Samuel  W.:    Two  Umbilical  Tumors  of  Probable  Uterine  Origin.     Surg.,  Gyn.  and 

Obstet.,  August,  1909,  249. 
Green:  Trans.  Path.  Soc.  London,  1899, 1,  243. 
Herzenberg:  Ein  Beitrag  zum  wahren  Adenom  des  Nabels.     Deutsche  med.  Wochenschr.,  1909, 

i,  889. 
Mintz,  W.:  Das  wahre  Adenom  des  Nabels.     Deutsche  Zeitschr.  f.  Chir.,  1899,  li,  545. 
von  Noorden,  W. :  Ein  Schweissdrtisenadenom  mit  Sitz  im  Nabel  und  ein  Beitrag  zu  den  Nabel- 

geschwulsten.  Deutsche  Zeitschr.  f.  Chir.,  1901,  lix,  215. 
Villar,  Francis:  Tumeurs  de  l'ombilic.  These  de  Paris,  1886. 
Wullstein,  L.-    Eine  Geschwulst  des  Nabels.     (Kombination  von  Cystadenom  der  Schweiss- 

driisen  mit  cavernosem  Angiom.)      Arb.  a.  d.  Path.  Inst,  in  Gottingen,  R.  Virchow,  zum  50. 

Doctor-Jubilaum,  1893,  245. 


CHAPTER  XXV. 
CARCINOMA  OF  THE  UMBILICUS. 

General  consideration. 

Classification. 

Primary  squamous-cell  carcinoma  of  the  umbilicus. 

Primary  adenocarcinoma  of  the  umbilicus;   report  of  cases. 

Carcinoma  of  the  umbilicus  secondary  to  carcinoma  of  the  stomach;  symptoms;  treatment;  de- 
tailed report  of  cases. 

Carcinoma  of  the  umbilicus  secondary  to  cancer  of  the  gall-bladder;  report  of  cases;  personal  ob- 
servation. 

Carcinoma  of  the  umbilicus  secondary  to  cancer  of  the  intestine;  report  of  cases. 

Carcinoma  of  the  umbilicus  secondary  to  ovarian  carcinoma;  report  of  cases;  personal  observa- 
tion. 

Carcinoma  of  the  umbilicus  secondary  to  carcinoma  of  the  uterus. 

Cases  of  secondary  carcinoma  of  the  umbilicus  in  which  the  source  of  the  primary  growth  was  not 
determined. 

A  retroperitoneal  carcinoma  accompanied  by  cancer  of  the  umbilicus. 

In  an  article  on  Surgical  Eiseases  of  the  Umbilicus  which  I  read  before  the 
Surgical  Section  of  the  American  Medical  Association  in  June,  1910,  and  which  was 
published  in  the  Journal  of  February  11,  1911,  the  subject  of  umbilical  cancer  was 
briefly  referred  to,  and  several  cases  that  had  come  under  my  observation  were 
reported.  In  the  present  article  cancer  of  the  umbilicus  will  be  much  more  fully 
considered,  and  the  cases  hitherto  recorded  in  the  literature  brought  together. 
Associated  intimately  with  the  early  development  of  the  subject. of  carcinoma  of  the 
umbilicus  are  the  names  of  Parker,*  Chuquet,f  Villarj  Feulard,§  Burkhart,|| 
Ledderhose,**  Neveujt  Morris,|J  Pernice,§§  Quenu  and  Longuet,||||  Le  Coniac,*** 
and  Besson.tft  Many  other  authors  have  enriched  the  literature  by  publishing 
individual  cases. 

Before  discussing  the  malignant  epithelial  growths  occurring  at  the  umbilicus, 
it  may  be  well  to  refresh  our  minds  as  to  the  histologic  appearance  of  the  normal 

*  Parker,  W. :  Excision  of  Umbilicus  for  Malignant  Disease.  Arch.  Clin.  Surg.,  New  York. 
1876-77,  i,  71. 

t  Chuquet :  Du  carcinome  generalise  du  peritoine.     These  de  Paris,  1879,  No.  548. 
i  Yillar,  Francis:  Tumeurs  de  1'ombilic.     These  de  Paris,  1886. 

§Feulard:  Fistule  ombilicale  et  cancer  de  l'estomac.  Arch.  gen.  de  med.,  1887,  7.  ser., 
xx,  158. 

||  Burkhart,  0.:  Ueber  den  Nabelkrebs.     Inaug.  Diss.,  Berlin,  1889. 
**  Ledderhose,  G.:  Deutsche  Chirurgie,  1890,  Lief.  45  b. 

ffNeveu:  Contribution  a  l'etude  des  tumeurs  malignes  secondaires  de  l'ombilic.  Paris, 
L890. 

%X  Morris:   .Malignant  Disease  of  the  Navel  as  a  Secondary  Complication.     Verhandl.  d.  10. 
Internat.  Med.  Cong.,  1890,  Berlin,  1891,  iii,  7.  Abth.,  122. 
§§  Pernice,  L.:  Die  Nabelgeschwiilste,  Halle,  1892. 

Qu£nu  and  Longuet :  Du  cancer  secondaire  de  l'ombilic.     Rev.  de  chir.,  1896,  xvi,  97. 
"*  Le  Coniac,  H.  C.  J. :    Cancer  secondaire  de  l'ombilic,  consecutif  aux  tumeurs  malignes 
de  l'appareil  utero-ovarien.     ThSse  <\<-  Bordeaux,  1898,  No.  19. 
-_„ttt  Besson,  E.:  Cancer  de  l'ombilic.     These  de  Paris,  1901,  No.  263. 

400 


CAKCINOMA    OF    THE    UMBILICUS.  401 

umbilicus  and  as  to  the  umbilical  lymphatics.  The  umbilical  scar  is  covered  over 
with  a  very  thin  squamous  epithelium  and  is  devoid  of  hair-follicles,  sweat-glands, 
and  sebaceous  glands. 

In  a  few  cases  remnants  of  the  omphalomesenteric  duct  have  been  detected  at 
the  umbilicus.  These  may  be  recognized  as  small  fistulous  tracts  or  as  cysts  lying 
between  the  peritoneum  and  the  rectus  muscle,  or  just  beneath  and  communicating 
with  the  skin.  In  a  few  instances  remnants  of  the  omphalomesenteric  duct  have 
been  present  as  small  tubular  glands  opening  directly  upon  the  surface  of  the  umbil- 
ical depression.  Such  a  case  has  been  particularly  well  described  by  Fox  and  Mac- 
Leod* (p.  268). 

From  the  above  description  it  is  evident  that,  while,  as  a  rule,  we  have  only  a 
very  attenuated  squamous  epithelium  at  the  umbilicus,  in  some  cases  cylindric 
epithelium  is  present.  Consequently  we  can  have  two  varieties  of  primary  car- 
cinoma in  this  region. 

The  careful  study  of  many  umbilical  lesions  in  the  past  has  demonstrated  that, 
when  the  liver  is  involved  in  a  malignant  growth  which  has  extended  to  or  encroached 
upon  the  suspensory  ligament,  the  growth  tends  to  pass  by  way  of  the  lymphatics 
out  along  the  suspensory  ligament  to  the  umbilicus.  Where  a  malignant  pelvic 
growth  extends  to  the  umbilicus,  it  usually  follows  the  lymphaties  found  in  the 
course  of  the  remnants  of  the  obliterated  umbilical  arteries  and  urachus  upward  to 
the  umbilical  depression.  If  the  umbilicus  is  the  seat  of  a  malignant  growth,  either 
the  inguinal  or  axillary  glands  may  be  secondarily  involved,  according  as  the  growth 
occupies  the  upper  or  lower  part  of  the  umbilicus.  The  lymphatics  of  the  umbilical 
region  are  considered  at  length  in  Chapter  II. 

From  a  study  of  the  literature  it  is  found  advisable  to  divide  carcinomata  of  the 
umbilicus  into  two  main  groups — those  that  are  primary,  and  those  that  are  secondary 
to  some  intra-abdominal  tumor.    Each  of  these  groups  may  be  subdiv  ded  as  follows : 

1.  Squamous-cell  carcinoma. 

2.  Adenocarcinoma. 

1.  From  the  stomach. 

2.  From  the  gall-bladder. 

3.  From  the  intestine. 

4.  From  the  ovaries. 

5.  From  the  uterus. 

6.  From  other  abdominal  organs. 


A.  Primarv  umbilical  carcinoma. 


B.  Secondary  umbilical  carcinoma,  i 


Cancer  of  the  umbilicus,  whether  primary  or  secondary,  is  exceptionally  rare.f 
Thus,  according  to  Parker  (1876),  Walshel  states  that  Tanchou  found  that  the 
mortuary  register  of  Paris  and  two  adjacent  arrondissements  yielded  9118  deaths 
from  cancer  between  the  years  1830-40  inclusive,  and  that  in  only  two  instances 
was  the  umbilicus  the  seat  of  the  carcinoma.  With  the  early  recognition  of  abdom- 
inal lesions  and  their  timely  surgical  treatment,  carcinoma  of  the  umbilicus  will  in 
all  probability  diminish  instead  of  increase. 

*  Fox  and  MacLeod:  A  Case  of  Paget's  Disease  of  the  Umbilicus.  Brit.  Jour.  Dermatol.,  1904, 
xvi,  41. 

1 1  have  carefully  read  Sir  William  Osier's  splendid  series  of  lectures  on  the  Diagnosis  of 
Abdominal  Tumors,  published  in  vols,  lix  and  lx  of  the  New  York  Medical  Journal,  1894.  but 
failed  to  find  any  case  in  which  the  umbilicus  was  the  seat  of  a  secondary  carcinoma. 

i  Walshe:  Nature  and  Treatment  of  Cancer,  London,  1S46,  92. 
27 


402  THE    UMBILICUS    AND    ITS    DISEASES. 

PRIMARY  SQUAMOUS-CELL  CARCINOMA  OF  THE  UMBILICUS. 

Malignant  squamous-cell  growths  occurring  at  the  umbilicus  are  exceedingly 
rare.  Hannay,*  in  1843,  reported  a  case  of  scirrhous  cancer  of  the  umbilicus.  A 
microscopic  examination  was.  however,  not  given,  and  it  is  impossible  to  determine 
whether  or  not  the  growth  was  primary. 

Pernice'sf  Case  77  from  Yolkmann's  clinic  is  more  suggestive.  The  patient  for 
a  long  while  had  had  an  umbilical  stone.  A  carcinoma  developed,  and  there  was  a 
purulent  secretion.  When  Volkmann  saw  him,  there  was  an  ulcerated  area  the 
size  of  a  thaler.  On  account  of  the  cauliflower-like  walls  the  growth  was  diagnosed 
as  a  cancroid  (squamous-cell)  carcinoma.  The  diagnosis  was  probably  correct, 
although  we  have  no  data  as  to  any  histologic  examination.  It  would  seem  that 
in  this  case  the  constant  irritation  of  the  foreign  body  had  stimulated  the  develop- 
ment of  a  malignant  growth. 

Pernice,  in  his  Case  79,  reports  another  carcinoma,  also  from  Yolkmann's  clinic. 
The  patient  was  a  man,  fifty-nine  years  of  age,  and  of  uncleanly  habits.  Xot 
long  before  admission  he  had  noticed  a  large  number  of  brownish-looking  spots  all 
over  the  body.  These  varied  in  size  from  a  finger-nail  to  a  lentil.  When  the  crusts 
were  removed,  there  was  free  bleeding.  For  six  or  eight  years  he  had  noticed 
moisture  around,  and  an  odor  from,  the  umbilicus.  He  consulted  a  physician,  who 
removed  several  small  particles  of  secretion.  The  walls  of  the  umbilicus  formed  a 
cuff  of  cancroid  or  epithelial  cancer.  When  Volkmann  saw  the  patient,  it  was  the 
size  of  a  thaler  and  secreted  a  great  deal.  There  was  marked  infiltration  of  the 
abdominal  wall.  The  abdomen  was  opened  during  the  operation.  The  patient 
died  of  sepsis  in  thirty-six  hours.  No  further  details  of  this  case  are  given.  The 
growth  was  evidently  a  primary  carcinoma  of  the  umbilicus,  and  in  all  probability 
had  developed  from  the  squamous  epithelium,  as  indicated  by  the  mode  of  origin 
and  the  slow  growth.  These  are  the  only  cases  I  could  find  suggesting  a  primary 
squamous-cell  carcinoma  of  the  umbilicus. 


PRIMARY  ADENOCARCINOMA  OF  THE  UMBILICUS. 
In  the  cases  reported  in  the  literature  it  is  very  difficult  to  determine  accurately 
whether  the  umbilical  tumors  were  primary  or  secondary.  Where  the  patient  gave 
no  history  of  any  abdominal  lesion,  and  where  careful  abdominal  inspection  before 
and  at  operation  brought  to  light  no  evidence  pointing  to  the  existence  of  any 
other  primary  abdominal  growth,  one  may,  with  a  relative  degree  of  certainty,  con- 
clude that  the  tumor  was  primary  at  the  umbilicus.  Still  it  must  be  remembered- 
— as  was  clearly  demonstrated  in  Valette's  case — that,  although  a  careful  visual 
and  manual  examination  may  fail  to  reveal  any  priman*  cancer  in  the  stomach, 
such  a  growth  may  nevertheless  exist.  In  Valette's  case,  when  the  umbilical 
growth  was  removed,  the  stomach  was  brought  up  into  the  wound  for  examina- 
tion, and  was  apparently  free  from  disease.  The  patient  died  of  peritonitis,  and  at 
autopsy  a  latent  carcinoma  of  the  stomach  was  found.  The  absence  of  an}*  abdom- 
inal symptoms  for  a  period  of  two  or  three  years  after  a  removal  of  an  umbilical 
carcinoma  is  the  most  certain  proof  that  the  growth  has  originated  in  the  umbilicus. 

*  Hannay:  Edin.  Med.  and  Surg.  Jour.,  1843,  lx,  313. 
t  Pernice,  L. :   Die  Nabelgeschwiilste,  Halle,  1892. 


CARCINOMA    OF    THE    UMBILICUS.  403 

Pernice  found  in  the  literature  21  cases  of  what  he  considered  primary  carcinoma 
of  the  umbilicus.  In  this  number  he  included  both  the  squamous-cell  and  the 
glandular  variety.  I  have  discarded  several  of  the  cases  included  in  his  group,  and 
have  added  several  recorded  since  his  valuable  monograph  was  written  in  1892 ;  and 
still  the  actual  number  of  cases  remains  uncertain.  In  the  cases  reported  by 
Dejerine  and  Sollier,  Bonvoisin,  Forgue  and  Riche,  Hue  and  Jacquin,  Maylard, 
Parker,  and  Tillaux  and  Barraud,  the  growths  seem,  without  a  doubt,  to  have 
been  primary.  The  growths  reported  by  Ajello,  Burkhart,  Despres,  Dannenberg, 
Demarquay,  Giordano,  Guiselin,  Heurtaux,  Ippolito,  Jores,  Lewis,  Stori,  and 
Wagner  were  also  probably  primary  adenocarcinomata  of  the  umbilicus,  although 
the  evidence  in  these  cases  is  not  quite  so  convincing.  In  Besson's  case  the  picture  \/ 
suggested  to  some  extent  the  presence  of  an  umbilical  tumor  containing  uterine 
glands.  Hertz's  case  need  be  only  mentioned  here.  From  the  description  the 
growth  does  not  seem  to  have  been  a  carcinoma,  but  resembled  in  some  degree  the 
type  of  umbilical  tumors  containing  uterine  glands. 

Pernice's  Case  78  bears  a  striking  resemblance  to  that  reported  b\r  Fox  and  Mac- 
Leod. The  man  was  seventy-two  years  of  age,  and  the  commencement  of  the  umbil- 
ical growth  dated  back  five  or  six  years.  It  was  the  size  of  a  two-mark  piece,  and 
was  here  and  there  covered  with  hard  crusts.  It  looked  very  much  like  a  rodent 
ulcer.  On  microscopic  examination  it  was  found  to  be  a  slowly  growing,  relatively 
benign  carcinoma  of  the  epithelium.  Here  and  there  a  definite  tendency  toward 
gland  formation  was  noted.  It  is  quite  possible  that  these  glands  were  remnants 
of  the  omphalomesenteric  duct,  and  that  the  proliferation  of  the  squamous  epi- 
thelium was  similar  to  that  noted  in  the  case  reported  by  Fox  and  MacLeod,  and 
designated  as  Paget's  disease  of  the  umbilicus. 

In  Doderlein's  case  and  in  Pernice's  Case  76,  although  the  umbilical  growths 
were  considered  as  primary,  they  would  seem  to  have  been  secondary  to  an  abdom- 
inal lesion. 

Primary  adenocarcinoma  of  the  umbilicus  usually  develops  as  a  very  small 
nodule  in  the  umbilical  depression,  which  may  grow  slowly  or  rapidly.  In  some 
cases  it  has  not  been  larger  than  a  small  nut;  in  others  it  has  reached  the  size  of  a 
walnut  or  a  hen's  egg.  Such  a  tumor  has  been  known  to  grow  to  the  size  of  a  five- 
franc  piece  in  the  course  of  six  months.  It  may  be  smooth  or  have  a  slightly  papil- 
lary surface.  With  the  increase  in  size  there  is  a  tendency  for  the  surrounding 
tissue  to  become  infiltrated.  The  central  portions  of  the  nodule  tend  to  ulcerate, 
and  these  areas  of  ulceration  may  be  covered  over  with  crusts.  The  ulceration  is 
naturally  accompanied  by  serous  secretion,  and  occasionally  by  some  bleeding. 

Histologically  nearly  all  these  growths  have  been  put  down  as  adenocarci- 
nomata of  the  type  usually  developing  from  the  small  intestine.  This  is  but  natural, 
as  they  originate  from  remnants  of  the  omphalomesenteric  duct. 

Age.  — In  the  cases  which  I  have  collected  and  in  which  the  age  was  given,  the 
youngest  patient  was  thirty-seven,  the  oldest,  seventy-six. 

Under  40  years 2  cases 

Between  40  and  50 2  cases 

"      50  and  60 7  cases 

"      60  and  70 6  cases 

"       70  and  80 5  cases 


29 


z  cases 


404  THE    UMBILICUS    AND    ITS   DISEASES. 

Sex.  —  Of  20  patients  of  whom  I  have  records  on  this  point,  9  were  men  and 
11  women.     This  tends  to  show  that  the  disease  is  equally  prevalent  in  both  sexes. 

Treatment.  — This  naturally  consists  in  the  wide  removal  of  the  umbilicus, 
care  being  taken  not  to  spread  the  carcinoma  cells  into  the  surrounding  healthy 
abdominal  wall.  The  inner  surface  of  the  umbilicus  should  be  carefully  examined 
to  see  if  adhesions  exist,  and  then,  after  fresh  abdominal  dressings  have  been  applied, 
a  systematic  inspection  of  the  abdominal  viscera  should  be  made  to  exclude  the 
possibility  of  carcinoma  of  the  stomach,  intestine,  or  pelvic  organs.  If  no  abdom- 
inal focus  be  found,  and  provided  a  wide  removal  of  the  growth  has  been  possible, 
the  prognosis  is  relatively  good. 

Detailed  Report  of  Cases  of  Primary  Adenocarcinoma  of  the  Umbilicus. 

In  the  majority  of  the  cases  the  umbilical  tumors  were  undoubtedly  primary,  but 
in  several  it  is  not  certain  that  they  were  not  secondary  to  some  intra-abdominal 
growth. 

A  Primary  Adenocarcinoma  of  the  Umbilicus.  [  ?  ]  — 
Ajello's*  patient  was  a  woman,  sixty-four  years  old,  from  whom  an  umbilical  growth 
was  removed.  He  gives  a  picture  of  the  outer  surface  and  also  of  the  smooth  peri- 
toneal surface  of  the  tumor. 

Histologic  examination  showed  a  definite  regular  glandular  growth.  Ajello 
then  discusses  the  literature. 

Primary  Cancer  of  the  Umbilicus.  —  Bessonf  reports  the  case 
of  a  woman  thirty-seven  years  of  age.  The  patient's  father  had  died  of  some  pul- 
monary trouble,  the  mother  of  cancer.  This  woman,  ten  years  before,  on  making  an 
extra  effort,  had  complained  of  intense  pain  at  the  umbilicus,  and  later  noticed  a 
small  tumor  developing  in  the  umbilical  cicatrix.  It  was  the  size  of  the  last 
phalanx  of  the  index-finger,  and  was  hard  in  consistence.  Elevation  of  the  arms 
increased  the  sensitiveness  at  the  umbilicus.  The  region  was  also  somewhat  painful 
at  the  menstrual  period.  The  patient  had  been  assured  that  the  tumor  was  not 
reducible.  It  had  increased  in  size  quite  slowly.  According  to  the  patient,  dur- 
ing the  last  four  months  it  had  become  painful  and  larger,  and  the  skin  had  become 
violet  in  color.  There  had  been  some  emaciation,  associated  with  paleness.  When 
the  patient  entered  the  hospital,  the  umbilical  cicatrix  formed  a  crescent  with  the 
concavity  directed  downward.  Palpation  showed  that  this  elevation  was  produced 
by  a  solid  tumor  which  was  hard  and  about  the  size  of  a  mandarin  orange.  The 
skin  was  not  movable  over  the  tumor,  as  it  was  adherent  at  the  umbilical  cicatrix. 
The  tumor  was  removed,  and  the  patient  made  a  good  recovery. 

Histologic  examination  showed  that  it  was  composed  of  fibrous  tissue  and  of  a 
glandular  growth  similar  to  that  developing  from  intestinal  glands.  When  seen 
four  years  later,  the  patient  was  perfectly  well.  The  growth  was  diagnosed  as  a 
cylindric-cell  carcinoma.  It  had  developed  at  the  umbilical  cicatrix,  and  was 
covered  with  skin.  It  consisted  of  fibrous  tissue  and  glands  lined  with  cylindric 
epithelium  resembling  that  of  the  adult  or  embryonic  Lieberkuhn's  glands.  The 
epithelial  cells  had  infiltrated  into  the  stroma,  and  there  was  a  tendency  to  invade 
the  surrounding  tissue. 

*  Ajello:    Contribute  alia  genesi  embrionale  di  un  adeno-epitelioma  cistico  primitivo  dell' 
ombelico.      From  Tansini's  Clinic. j     La  Riforma  medica,  1899,  anno  15,  iii.  663. 
f  Besson :  Cancer  de  l'ombilic.     These  de  Paris,  1901,  No.  263,  66. 


CARCINOMA    OF    THE    UMBILICUS.  405 

Primary  Adenocarcinoma  of  the  Umbilicus.  —  Bon- 
voisin,*  after  citing  a  case  already  described  by  Tillaux,  reports  a  second  also  from 
Tillaux's  service.  The  patient,  a  man  sixty-four  years  of  age,  had  the  general 
appearance  of  a  sick  person.  He  had  been  ill  for  about  two  months.  At  the 
umbilicus  was  a  brawny  excrescence.  There  was  no  history  of  injury.  When  the 
nodule  was  first  noticed  it  was  the  size  of  a  small  pea.  In  about  fifteen  days  it 
commenced  to  ulcerate  and  the  physician  thought  it  was  eczema.  At  the  time  of 
Tillaux's  examination  the  umbilicus  had  disappeared  and  had  been  replaced  by  a 
shallow  area  of  ulceration  covered  with  a  blackish  crust  surrounded  by  an  area  of 
inflammation  several  millimeters  in  diameter.  The  total  zone  of  inflammation 
was  the  size  of  a  five-franc  piece  and  about  1  cm.  broad.  The  mass  was  im- 
mobile vertically,  but  could  be  pushed  from  side  to  side.  There  was  no 
enlargement  of  the  axillary  or  inguinal  glands. 

The  umbilicus  was  removed,  but  the  patient  died.  Autopsy  failed  to  reveal  any 
peritonitis,  and  the  peritoneal  portion  of  the  growth  was  free  from  adhesions.  The 
stomach  and  intestines  were  normal.  The  growth  was  a  primary  adenocarcinoma 
of  the  umbilicus  and  had  evidently  originated  from  remains  of  a  fetal  structure. 
Ducellier  made  the  microscopic  examination  in  Prof.  CorniFs  laboratory. 

Primary  Carcinoma  of  the  Umbilicus.  —  Dannenbergt 
reports  the  case  of  a  day  laborer,  seventy-one  years  old,  operated  upon  by  Maas. 
For  three  months  before  admission  he  had  complained  of  pain  in  the  umbilicus,  and 
now  showed  an  umbilical  tumor  3  cm.  broad,  2.5  cm.  long,  and  raised  5  mm.  above 
the  surface  of  the  abdomen.  There  was  a  dark-red,  funnel-shaped  ulceration  in  the 
middle.  The  tumor  was  firm  in  consistence  and  the  surrounding  tissue  was  infil- 
trated. There  was  pain  on  contraction  of  the  abdominal  muscles,  and  swelling 
in  the  inguinal  glands,  more  marked  on  the  left  than  on  the  right  side.  The  appe- 
tite was  good.  When  the  tumor  was  removed,  the  peritoneum  was  found  perfectly 
free  at  the  umbilicus.     The  patient  made  a  good  recovery. 

Microscopically,  solid  nests  were  here  and  there  visible,  and  at  other  points 
cavities  lined  with  one  layer  of  cylindric  epithelium.  The  tumor  was  diagnosed  as 
a  scirrhous  carcinoma,  but  from  the  description  it  would  seem  to  have  been  an 
adenocarcinoma.  [Although  there  are  many  points  suggesting  a  primary  growth 
in  this  case,  in  the  absence  of  a  most  thorough  abdominal  examination  it  is  impossible 
to  say  that  it  might  not  have  been  secondary. — T.  S.  C] 

*>  Primary  Adenocarcinoma  of  the  Umbilicus.  J  —  At  an 
autopsy  on  a  man,  fifty-four  years  of  age,  who  had  had  tabes  for  eleven  years,  a  tu- 
mor of  the  umbilicus  was  found,  circular  in  form,  about  7  or  8  cm.  in  diameter  and 
5  to  6  cm.  thick.  It  lay  in  front  of  the  aponeurosis,  and  had  not  encroached  on 
the  peritoneum.  It  was  an  adenocarcinoma.  There  was  no  evidence  of  metas- 
tases.    This  tumor  was  looked  upon  as  a  primary  carcinoma  of  the  umbilicus. 

Carcinoma  of  the  Umbilicus.  —  Demarquay's§  patient,  fifty- 
four  years  of  age,  had  a  tumor  the  size  of  an  egg  at  the  umbilicus.  She  had  had  a 
congenital  nevus  at  the  umbilicus,  and  this  had  started  to  increase  in  size  two  years 

*  Bonvoisin,  G. :  Etude  pathogenique  et  histologique  sur  une  variete  de  l'epitheliome  de 
l'ombilic.     These  de  Paris,  1891,  No.  305. 

f  Dannenberg,  O. :  Zur  Casuistik  der  Nabeltumoren  insbesondere  des  Carcinoma  umbili- 
cale.     Inaug.  Diss.,  Wurzburg,  1886. 

t  Dejerine  et  Sollier:  Bull.  Soc.  anat,  de  Par.,  1888,  649. 

§  Demarquay:  Cancer  de  l'ombilic.     Bull.  Soc.  de  chir.  de  Par.  (1870),  1871,  2.  ser.,  xi,  209. 


406  THE    UMBILICUS    AND    ITS    DISEASES. 

before  her  admission.  The  tumor  had  become  excoriated,  was  painful,  and  there 
was  a  small  amount  of  hemorrhage.  Demarquay  hesitated  to  operate  on  account 
of  two  small  tumors  in  the  inguinal  region.  These,  however,  were  looked  upon 
as  papillomata  of  the  inguinal  glands,  not  malignant,  but  caused  by  irritation  from 
the  umbilical  growth.  The  general  health  of  the  patient  became  poor,  and  a 
fatal  issue  seemed  probable. 

/\  Carcinoma  of  the  Umbilicus  (Primary  or  Second- 
ary?) .* —  The  patient,  a  man  of  seventy-four  years,  complained  of  pain  when 
the  clothes  came  in  contact  with  the  umbilicus.  Situated  in  the  umbilicus  was 
a  reddish  nodule  the  size  of  a  pea,  which  was  slightly  blood-tinged.  The  tumor 
increased  rapidly  and  reached  the  size  of  a  two-franc  piece.  It  was  removed,  and 
examination  proved  it  to  be  an  adenocarcinoma.  There  were  no  signs  of  any 
other  growth. 
^  Primary  Adenocarcinoma  of  the  Umbilicus.  —  Doeder- 
lein'sf  patient  was  a  woman  fifty-five  years  of  age.  Three  months  before  admission 
she  had  first  noticed  a  small,  hard,  painful  tumor  at  the  umbilicus.  Four  weeks 
before  coming  under  observation  the  tumor  had  shown  a  small  ulcer  on  its  surface. 
The  physician  that  saw  her  had  diagnosed  inflammation  of  the  umbilicus,  and 
ordered  moist  applications.  The  condition  had  become  worse,  and  several  other 
ulcers  had  developed  around  the  umbilicus.  When  Doederlein  saw  her,  the  umbil- 
icus was  funnel-shaped  and  drawn  in.  The  entire  skin  of  the  umbilicus  was  very 
thick,  and  the  underlying  parts  were  fixed.  The  surface  was  ulcerated,  and  there 
was  a  serous  secretion.  In  the  vicinity  of  the  umbilicus  were  numerous  dilated 
blood-vessels.  Diffusely  scattered,  particularly  toward  the  symphysis,  were  small 
hard  nodules  in  the  skin,  the  size  of  millet-seeds  or  linseeds.  These  on  pressure 
were  not  painful.  In  both  inguinal  regions  were  hard  packets  of  tumors  the  size 
of  a  goose's  eggs.  They  were  somewhat  movable,  and  on  pressure  were  not  painful. 
Under  anesthesia  the  umbilicus  was  widely  removed.  When  the  abdomen  was 
opened,  the  peritoneum  in  the  vicinity  of  the  umbilicus  was  found  to  contain  numer- 
ous small  nodules.  The  umbilical  tumor  was  removed,  and  the  inguinal  growths 
were  dissected  out.     The  patient  died  ten  days  later  in  collapse. 

The  portion  of  the  abdominal  wall  removed  was  20  by  12  by  4  cm.,  and  the 
umbilical  funnel  was  2.5  cm.  deep.  The  skin  over  the  prominence  of  the  umbilicus 
was  somewhat  stretched.  On  both  sides  of  the  umbilical  depression  were  small 
superficial  ulcers.  These  had  irregular  margins  and  somewhat  reddened  and  dirty 
surfaces.  In  general  the  condition  suggested  that  the  depth  of  the  umbilicus  had 
consisted  of  small  tumors  which  had  pressed  the  skin  forward  and  tended  to  break 
through.  On  palpation  one  could  feel  the  nodules  beneath  the  surface  of  the  skin, 
and  in  the  umbilical  depression  they  merged  with  one  another,  forming  a  hard  mass. 
A  sharp  outline  between  the  skin  and  the  tumor  was  macroscopically  impossible. 

On  histologic  examination  the  umbilical  growth  was  found  to  be  an  adeno- 
carcinoma; the  enlargement  in  the  inguinal  glands  was  also  due  to  carcinomatous 
involvement. 

The  liver  contained  about  20  irregular,  small  metastases  on  its  surface.  These 
varied  from  a  millet-seed  to  a  bean  in  size.  There  was  also  one  on  the  anterior 
surface  of  the  gall-bladder.     The  gall-bladder  contained  stones.     In  the  visceral 

*  Despres:  Bull,  et  Mem.  Soe.  de  chir.  de  Par.,  1883,  ix,  245. 

t  Doederlein,  F.:  Ein  primares  Adenokarzinom  des  Nabels.     Inaug.  Diss.,  Erlangen,  1907. 


CARCINOMA    OF    THE    UMBILICUS.  407 

peritoneum  were  about  60  or  80  nodules.  Doederlein  came  to  the  conclusion  that 
the  growth  in  the  gall-bladder  was  a  secondary  one. 

[From  the  evidence  at  hand  it  is  impossible  for  us  to  determine  whether  the 
umbilical  carcinoma  was  primary  or  secondary. — T.  S.  C] 

<?v  P  r  i  m  a  r  y  Adenocarcinoma  of  the  U  mbilicus.  —  Forgue 
and  Riche*  report  the  case  of  a  woman,  aged  fifty-six,  who  six  months  before  coming 
under  observation  had  noticed  a  reddish  point  at  the  umbilicus.  At  the  time  she 
was  operated  on  it  was  the  size  of  a  five-franc  piece  and  indurated,  and  for  four 
months  there  had  been  a  slight  ulceration  which  emitted  at  times  a  bloody  dis- 
charge. Xo  abdominal  tumor  could  be  demonstrated  at  operation.  The  pelvis 
was  empty;  no  enlarged  glands  could  be  detected.  The  tumor  was  removed1,  and 
on  microscopic  examination  proved  to  be  a  typical  adenocarcinoma.  The  glands 
in  some  places  resembled  those  of  Lieberkiihn. 

The  patient  was  well  twenty-two  months  after  operation.  This  tumor  would 
seem  to  have  been  a  primary  adenocarcinoma  which  had  probably  developed  from 
remains  of  the  omphalomesenteric  duct. 

\>  Probable  Primary  Carcinoma  of  the  Umbilicus. -|  — ■ 
The  patient,  a  porter  aged  thirty-eight,  had  a  papillary-like  growth  at  the  umbilicus 
from  which  there  was  bloody  discharge.  The  growth  varied  from  10  to  15  mm.  in 
diameter.  The  pictures  given  by  Giordano  are  excellent.  He  thought  he  was  deal- 
ing with  a  primary  carcinoma  of  the  umbilicus.  He  gives  a  short  review  of  the 
literature. 

Primary  Carcinoma  of  the  Umbilicus.  —  Guiselint  reports 
a  case  observed  by  Villar  that  had  not  yet  been  published.  The  woman  was  sixty- 
four  years  of  age,  a  music  teacher.  Her  father  had  died  at  seventy  of  cancer  of  the 
tongue.  For  five  months  she  had  noticed  a  small,  painless  enlargement  at  the 
umbilicus.  The  tumor  had  increased  gradually  in  size  and  had  become  reddish  in 
color  during  the  two  months  before  she  was  seen  by  Guiselin.  On  examination  the 
umbilicus  was  found  to  be  violet  in  color,  and  a  tumor,  the  size  of  a  hazelnut, 
occupied  the  umbilical  depression.  It  presented  bosses,  was  hard,  adherent,  and 
reducible.  When  the  abdomen  was  opened,  no  tumor  could  be  made  out  in  the 
intestinal  tract,  stomach,  liver,  or  genital  organs. 

Histologic  examination  showed  the  growth  to  be  epithelial  in  character  and  of 
a  cylindric  type.     It  appeared  to  be  a  primary  adenocarcinoma  of  the  umbilicus. 

Adenocarcinoma  of  the  Umbilicus.  [?]§  —  The  woman,  fifty- 
eight  years  of  age,  had  a  tumor  the  size  of  a  small  hazelnut  at  the  umbilicus.  This 
was  very  soft  and  reddish  gray  in  color.  Microscopic  examination  showed  gland- 
spaces  surrounded  with  loose  connective  tissue.  The  epithelium  in  some  places 
was  one  and  in  others  several  layers  in  thickness.  There  were  also  "  Schichtungs- 
perlen, "  but  a  real  hornification  did  not  exist.  In  other  places  there  was  a  definite 
malignant  growth  of  the  glands.  Hertz  says  that,  although  the  growth  was  malig- 
nant, it  must  have  developed  from  the  epithelium  of  the  intestine  or  of  the  omphalo- 

*  Forgue  et  Riche:  Alontpellier  med.,  1907,  2.  s.,  xxiv,  145-169. 

t  Giordano,  D. :  Sopra  un  caso  di  cancro  dell'  ombelico.     La  Medicina  Italiana,  1911,  ix,  6. 
+  Guiselin:  Du  cancer  de  l'ombilic.     These  de  Bordeaux,  1906,  No.  47. 

§  Hertz:  L'eber  einen  Fall  von  Adenocarcinom  des  Nabels  bei  einer  5S-Jahrigen  Frau. 
Inaug.  Diss.,  Wurzburg,  1905. 


408  THE    UMBILICUS    AND    ITS    DISEASES. 

mesenteric  duct.  [The  growth  strongly  suggests  an  umbilical  tumor  containing 
uterine  glands. — T.  S.  C] 

Carcinoma  of  the  Umbilicus.*  —  The  patient  was  fifty-one  years 
old.  A  small  tumor  had  developed  at  the  umbilicus  a  few  months  after  she  had 
received  a  blow.  Microscopic  examination  showed  that  it  was  a  cylindric-cell 
carcinoma. 

Probable  Primary  Cancer  of  the  Umbilicus.f — The 
patient,  a  soldier  forty-five  years  of  age,  had  a  nodule  at  the  umbilicus.  This  was 
opened  and  was  thought  to  contain  pus,  although  there  was  only  a  slight  discharge. 
It  became  fungating,  and  grew  as  large  as  a  fist.  There  was  bladder  involvement. 
Whether  the  growth  was  primary  or  not  was  uncertain. 

Microscopic  examination  showed  that  it  was  a  carcinoma,  apparently  of  the 
adenocarcinomatous  type.     Autopsy  revealed  no  growth  in  the  intestine  or  stomach. 

The  fungating  process  was  probably  hastened  as  a  result  of  the  cutting; 
consequently  I  omit  any  description  of  the  umbilicus. 

Adenocarcinoma  of  the  Umbilicus.  —  IppolitoJ  gives  a  brief 
review  of  the  literature  and  then  reports  the  case  of  a  woman  fifty-one  years  of  age. 
An  umbilical  growth  was  removed,  which  microscopically  proved  to  be  an  adeno- 
carcinoma of  the  intestinal  type.  Ippolito  thought  it  was  primary,  but  there  is 
no  note  made  of  any  careful  abdominal  examination.  [Possibly  it  was  a  secondary 
growth.— T.  S.  C] 

Probable  Adenocarcinoma  of  the  Umbilicus. §  —  The 
tumor  was  removed  by  Professor  Witzel;  it  was  the  size  of  a  walnut.  The  peri- 
toneum was  intact.  The  tumor  on  section  was  hard,  firm,  and  appeared  to  be 
encapsulated  in  fibrous  tissue.  On  microscopic  examination  it.  proved  to  be  an 
adenocarcinoma  of  the  type  resembling  that  usually  found  developing  in  the 
stomach.  Examination  of  the  patient  did  not  give  any  evidence  of  cancer  in  the 
abdomen.     This  was  probably  a  primary  growth. 

A  Malignant  Tumor  in  an  Umbilical  Hernial  Sac.  j |  — 
The  patient  was  sixty-seven  years  of  age  and  had  had  an  umbilical  hernia  for  fifteen 
years.  No  truss  had  been  used,  but  the  hernia  had  been  reduced  without  difficulty 
until  a  year  before.  Pain  in  the  umbilicus  increased  rapidly  and  radiated  to  the 
stomach  and  the  pelvic  region.  The  patient  lost  flesh  and  strength  and  had  fre- 
quent vomiting,  with  constipation  and  diarrhea. 

On  examination  a  hard,  nodulated,  bluish-red  tumor  was  found  at  the  umbilicus. 
Its  surface  was  slightly  ulcerated.  The  sac  contained  omentum,  which  was  not 
diseased,  and  also  subperitoneal  tissue  infiltrated  as  far  as  a  finger  could  reach. 
The  growth  was  removed,  but  the  patient  died  of  shock  six  hours  later.  Micro- 
scopic examination  showed  a  malignant  growth,  which  the  author  thought  was  a 
sarcoma  connected  with  Lieberkiihn's  glands,  although  he  questioned  whether  or 
not  it  might  represent  remains  of  the  omphalomesenteric  duct.  The  case  is  not 
very  clear,  but  the  tumor  was  evidently  malignant. 

*  Heurtaux:  Epitheliome  de  l'ombilic.     Gaz.  med.  de  Nantes,  18S6,  iv,  46. 

t  Hue  et  Jacquin:  Cancer  colloid  e  de  la  l'ombilic  et  de  paroi  abdominale  anterieure  ayant 
envahi  la  vessie.     L'Union  med.,  1868,  3.  ser.,  vi,  418. 

i  Ippolito:    t  it  caso  d'epitelioma  dell'ombelico.     Gazz.  Internaz.  di  med.,  1901,  iv,  302. 

§  Jores:  Cylinder-Epithelkrebs  des  Nabels.  Vereins-Beilagc  der  Deutsch.  med.  Wochen- 
schr.,  1899,  xxv,  22. 

||  Lewi.-,:  Med.  Record,  1889,  xxxvi,  394. 


CARCINOMA    OF    THE    UMBILICUS.  409 

Cylindric-cell  Carcinoma  of  the  Umbilicus.*  —  The 
specimen  was  from  a  man  sixty-five  years  of  age.  For  two  months  before  admission 
he  had  complained  of  pain  in  the  lumbar  region.  He  had  not  noticed  the  umbilical 
nodule  until  it  was  pointed  out  to  him  by  the  doctor.  A  small  projection  the  size 
of  a  pea  was  readily  seen  and  felt  in  the  pit  of  the  umbilicus.  On  deep  palpation 
it  appeared  to  be  larger.  It  was  removed  through  an  elliptic  incision.  The  peri- 
toneal surface  was  puckered.     On  section,  the  tumor  presented  a  solid  appearance. 

Microscopic  examination  showed  a  cylindric-cell  carcinoma.  Maylard  sug- 
gested that  it  had  developed  from  the  omphalomesenteric  duct.  Macewen,  in  the 
discussion  at  the  Glasgow  Path,  and  Clin.  Society,  before  which  this  case  was 
reported,  said  he  had  seen  two  similar  cases,  but  when  brought  to  him  both 
patients  already  had  advanced  peritoneal  disease.  Each  of  the  umbilical  growths 
was  considered  primary.  In  one  case  pain  in  the  back  was  thought  to  be  due 
to  the  involvement  of  the  liver,  as  found  at  autopsy. 

Primary      Carcinoma      of     the      Umbilicus. f  —  A     woman 
seventy-six  years  of  age,  had  a  malignant  growth  at  the  umbilicus.     The  disease 
gradually  progressed  and  she  died.     At  autopsy  the  feasibility  of  an  operation  for 
the  removal  of  the  mass  forcibly  impressed  itself  on  Parker.     The  growth  was  evi- 
dently primary. 

Primary  Carcinoma  of  the  Umbilicus.  %  —  Case  76. — 
Volkmann  removed  from  a  man,  seventy-four  years  of  age,  a  squamous-cell  car- 
cinoma the  size  of  a  hen's  egg  from  the  umbilicus.  The  omentum  was  already 
degenerated  with  carcinomatous  nodules,  and  death  followed  five  months  later 
with  abdominal  carcinoma  and  ascites.     The  growth  was  not  glandular. 

Primary  Carcinoma  of  the  Umbilicus. §  — ■  Case  78. — A  for- 
ester, seventy-two  years  of  age,  came  to  Volkmann  suffering  from  an  ulceration  at 
the  umbilicus  the  size  of  a  two-mark  piece,  which  had  first  begun  some  five  or  six 
years  previously.  Here  and  there  it  was  covered  with  hard  crusts.  The  condition 
strongly  suggested  a  rodent  ulcer.  On  microscopic  examination  it  proved  to  be  a 
slowly  growing,  relatively  benign,  carcinoma.  The  slightly  thickened  walls  of  the 
ulcer  were  excised,  the  abscess  was  cureted  out  and  freely  cauterized,  and  a  plaster 
laid  over  it.  The  wound  healed  speedily,  and  the  man  had  no  return  of  the  growth, 
but  died  of  pneumonia  four  or  five  years  later.  Examination  of  the  tumor  showed 
no  evidence  of  a  horny  layer  or  of  nests  of  cells  resembling  those  of  the  rete  Malpighii . 
Here  and  there  was  a  definite  tendency  toward  gland  formation. 

[It  is  quite  possible  that  in  this  case  there  were  remains  of  the  omphalomesenteric 
duct  at  the  umbilicus,  as  seen  in  Fox  and  MacLeod's  case,  which  they  diagnosed  as 
Paget's  disease  of  the  umbilicus  (see  p.  268). — T.  S.  C] 

Adenocarcinoma  of  the  Umbilicus. ||  —  The  patient,  sixty- 
eight  years  of  age,  for  nearly  a  year  had  complained  of  discomfort  just  above  the 
umbilicus,  which  was  continuous  and  independent  of  digestion.  At  the  umbilicus 
was  an  indurated  area,  the  size  of  a  pigeon's  egg.     When  seen  at  operation,  it  was 

*  Maylard:  Trans.  Glasgow  Path,  and  Clin.  Soc,  1886-91;  1892,  iii,  294. 

t  Parker:  Excision  of  Umbilicus  for  Malignant  Diseases.  Arch.  Clin.  Surg.,  Xew  York, 
1876-77,  i,  71. 

J  Pernice,  L. :   Die  Nabelgeschwulste,  Halle,  1892. 

§  Pernice,  L.:   Op.  cit. 

||  Stori:  Contribute  alio  studio  dei  tumori  dell'ombelico.  Lo  Sperimentale,  Arch,  di  biologia 
normale  e  patologia,  1900,  liv,  25. 


410  THE    UMBILICUS    AND    ITS    DISEASES. 

ovoid  in  form,  6  cm.  in  its  longest  diameter,  and  4  cm.  broad.  It  seemed  to  be  a 
primary  tumor  of  the  abdominal  wall.  It  was  removed,  and  the  patient  died  of  perito- 
nitis.    Microscopic  examination  showed  that  the  growth  was  an  adenocarcinoma. 

[Whether  this  was  primary  or  secondan-  is  uncertain. — T.  S.  C] 

Carcinoma  of  the  Umbilicus  Developing  in  the  Depth 
of  an  Umbilical  Diverticulum.*  —  The  patient,  a  woman  forty 
years  of  age,  entered  the  hospital  for  an  umbilical  tumor.  In  childhood  she  had 
had  no  serious  diseases.  Seven  months  previously,  while  bathing,  she  had  noticed 
a  small  crust  at  the  umbilicus.  This  she  had  removed,  and  had  seen  a  small,  dark- 
red  tumor  the  size  of  a  lentil.  There  was  no  ulceration  and  no  discharge.  It  had 
increased  steadily  in  size  and  had  been  cauterized,  but  had  reappeared  as  a  small 
but  rapidly  growing  tmnor.  At  the  end  of  three  weeks  it  had  ulcerated,  and  there 
had  been  slight  hemorrhages.  On  admission  the  entire  umbilicus  was  found  trans- 
formed into  a  tumor  about  the  size  of  a  ten-centime  piece.  It  was  .circular  and 
bulging.  It  was  dark  red,  ulcerated,  and  cup-shaped  over  an  area  the  size  of  a  five- 
centime  piece.  The  surrounding  tissue  was  indurated.  No  axillary  or  inguinal 
gland  enlargement  was  noted.  The  patient  was  in  good  condition  and  had  no 
indigestion.  An  extensive  removal  was  made.  The  omentum  was  not  adherent, 
and  no  abdominal  lesion  was  noted.     Recovery  followed. 

Cornil  made  the  following  report:  "The  tumor  consists  of  a  cylindric-cell  epi- 
thelioma. The  epithelioma  is  analogous  to  that  which  develops  primarily  in  the 
intestinal  glands."  [Of  course,  the  length  of  time — about  four  months — was  too 
short  to  warrant  a  final  prognosis. — T.  S.  C] 

Carcinoma  of  the  Umbilicus,  f  —  A  woman,  aged  forty,  who  had 
had  12  children,  two  years  previously  had  noticed  two  pea-sized  bodies  in  the  skin 
on  the  left  side  of  the  umbilicus,  winch  had  grown  gradually  for  eighteen  months. 
Blisters  had  formed  and  broken,  discharging  a  foul-smelling  pus.  On  admission 
the  tumor  was  43^  inches  in  its  longest  diameter  and  11  inches  in  circumference; 
it  was  lobulated  and  had  a  dirty,  ulcerated  surface,  covered  with  a  foul-smelling 
discharge.  Xo  other  local  manifestations  were  detected.  The  growth  was  re- 
moved in  1816  and  the  patient  recovered.  Naturally,  at  that  time  there  was  no 
microscopic  examination. 
^  [The  duration  is  strongly  indicative  that  this  growth  was  primary,  in  view  of 
the  fact  that,  when  the  umbilical  growth  is  secondary,  the  primary  tumor  usually 
causes  death  in  the  course  of  five  or  six  months. — T.  S.  C] 

A  Supposed  Sub  malignant  Adenocarcinoma  of  the 
Umbilicus. —  From  the  history  this  growth  seems  to  have  been  primary.  Its 
situation  and  relation  would  suggest  its  origin  from  the  urachus,  but  Koslowski  says 
that  the  glands  in  it  were  of  the  intestinal  type.  It  is  probable  that  it  had  developed 
from  extraperitoneal  remnants  of  the  omphalomesenteric  duct.  As  it  does  not 
nsemble  any  case  heretofore  described,  I  have  allotted  it  a  separate  place. 

Koslowski'si  patient  was  operated  upon  in  October,  1902.  Five  weeks  before, 
he  had  noticed,  in  the  mid-line,  between  the  symphysis  and  umbilicus,  a  small 

*  Tillaux  and  Barraud:  Epithelioma  de  l'ombilie,  developpe  aux  depens  d'un  diverticule 
intestinal;  omphalectomie,  guerison.     Annales  de  Gyn.,  Paris,  1887,  xxvii,  401. 

f  Wagner:  Abtragung  eines  carcinomatosentarteten  Nabels.  Med.  Jahrb.  d.  k.  k.  oster. 
31  lates,  Wien,  1839,  n.  F.,  xviii,  .585-589. 

i  Koslowski:  Ein  Fall  von  wahrem  Xabeladenom.  Deutsche  Zeitschr.  f.  Chir.,  1903,  lxix, 
469. 


CARCINOMA    OF   THE   UMBILICUS.  411 

painful  tumor  which  grew  to  the  size  of  a  walnut.  The  abdominal  pain  radiated. 
On  examination  the  man,  although  only  fifty-five  years  old,  was  markedly  emaciated 
and  looked  as  if  he  were  about  seventy.  He  had  had  frequent  diarrhea.  He  was 
bent  over  as  if  guarding  the  abdominal  muscles.  Between  the  umbilicus  and  the 
symphysis,  near  the  mid-line,  was  a  tumor  reminding  one  of  a  patella.  The  over- 
lying skin  was  free.  The  tumor  was  very  painful  and  slightly  movable.  It  felt 
dense  and  gradually  merged  into  the  surrounding  tissue.  Toward  the  umbilicus 
was  a  cord  the  size  of  a  goose-quill.  The  growth  was  thought  to  be  a  malignant 
epithelial  tumor  of  the  urachus. 

A  median  incision  showed  that  the  tumor  had  grown  through  the  linea  alba  and 
the  sheath  of  the  rectus.  A  portion  of  the  rectus  muscle,  of  the  transversalis  fascia, 
and  of  the  peritoneum  were  removed.  After  the  abdomen  had  been  opened  and 
the  tumor  had  been  drawn  up,  fibrous  cords  were  seen  passing  from  the  umbilicus. 
The  upper  one  was  the  size  of  a  goose-quill,  firm  and  infiltrated;  the  lower  contained 
a  venous  cord,  was  less  firm,  and  passed  into  the  vesico-umbilical  ligament.  The  peri- 
toneum covering  the  posterior  surface  of  the  tumor  showed  evidence  of  scarring  and 
of  ulceration.     The  patient  made  a  good  recovery. 

The  tumor  in  form,  as  mentioned  above,  resembled  a  patella.  The  peritoneum 
was  firmly  attached  to  it,  and  the  surrounding  muscle  had  been  penetrated  by  it. 
On  microscopic  examination  the  growth  was  found  to  be  made  up  of  glands  varying 
in  size  between  that  of  a  urinary  tubule  and  that  of  a  gland  large  enough  to  be 
seen  with  the  naked  eye.  The  diagnosis  was  fibro-adenocarcinoma  submalignum. 
The  glands  resembled  those  of  the  intestinal  type. 


LITERATURE  CONSULTED  ON  PRIMARY  CARCINOMA  OF  THE  UMBILICUS. 

Ajello:   Contributo  alia  genesi  embrionale  di  un  adeno-epiteliorna  cistico  primitivo  deU'ombelico 

(from  Tansini's  clinic).     La  Riforma  medica,  1899,  Anno  15,  iii,  663. 
Besson,  E. :  Cancer  de  l'ombilic.     These  de  Paris,  1901,  No.  263. 
Bonvoisin,  G. :   Etude  pathogenique  et  histologique  sur  une  variete  de  l'epitheliome  de  1'ombilic. 

These  de  Paris,  1891,  No.  305. 
Burkhart,  O.:  Ueber  den  Nabelkrebs.     Inaug.  Diss.,  Berlin,  1889. 
Chuquet:  Du  carcinome  generalise  du  peritoine.     These  de  Paris,  1879,  No.  548. 
Dannenberg,  O. :  Zur  Casuistik  der  Nabeltumoren  insbesondere  des  Carcinoma  uuibilicale.    Inaug. 

Diss.,  Wiirzburg,  1886. 
Dejerine  et  Sollier:  Bull.  Soc.  anat.  de  Paris,  1888,  649. 

Demarquay:  Cancer  de  l'ombihc.     Bull.  Soc.  de  Chir.  de  Par.  (1870),  1871,  2.  s.  xi,  209. 
Despres:  Bull,  et  Mem.  Soc.  de  chir.  de  Paris,  1883,  ix,  245. 

Doederlein,  F. :  Ein  primares  Adenokarzinom  des  Nabels.     Inaug.  Diss.,  Erlangen,  1907. 
Fox  and  MacLeod:  A  Case  of  Paget's  Disease  of  the  Umbilicus.     Brit.  Jour.  Dermatol.,  1904,  xvi, 

41. 
Forgue  et  Eiche:  Montpellier  med.,  1907,  2.  s.,  xxiv,  145-169. 

Feulard:  Fistule  ombilicale  et  cancer  de  l'estomac.     Arch.  gen.  de  med  ,  18S7,  7.  ser.,  xx,  158. 
Giordano,  D.:  Sopra  un  caso  di  cancro  dell'ombilico.     La  Medicina  Italiana,  1911,  ix,  6. 
Guiselin,  E.  J.  M.  J. :  Du  cancer  de  l'ombihc.     These  de  Bordeaux,  1906,  No.  47. 
Hertz,  W.  H.:    Uber  einen  Fall  von  Adenocarcinom  des  Nabels  bei  einer  58-Jahrigen  Frau. 

Inaug.  Diss.,  Wiirzburg,  1905. 
Heurtaux:  Epitheliome  de  l'ombilic.     Gaz.  med.  de  Nantes,  1886,  iv,  46. 
Hue  et  Jacquin:  Cancer  colloide  de  l'ombihc  et  de  la  paroi  abdominale  anterieure  ayant  envahi 

la  vessie.     L'Union  medicale,  1868,  3.  ser.,  vi,  418. 


412  THE    UMBILICUS    AND    ITS    DISEASES. 

Ippolito,  G. :  Un  caso  epitelioma  dell'ombelico.     Gaz.  internaz.  di  med.,  1901,  iv,  302. 

Jores:  Cylinder-Epithelkrebs  des  Nabels.   Vereins-Beilage  der  Deutsch.  med.  Wochenschr.,  1899, 

xxv,  iv,  22. 
Koslowski:  Ein  Fall  von  wahrem  Nabeladenom.     Deutsche  Zeitschr.  f.  Chir.,  1903,  lxix,  469. 
Ledderhose,  G. :  Deutsche  Chirurgie,  1890,  Lief.  45  b. 

Lewis,  D.:  A  Malignant  Tumor  in  an  Umbilical  Hernial  Sac.     Medical  Record,  1889,  xxxvi,  394. 
Le  Coniac,  H.  C.  J.:    Cancer  secondaire  de  l'ombilic,  consecutif  aux  tumeurs  malignes  de  l'ap- 

pareil  utero-ovarien.     These  de  Bordeaux,  1898,  No.  19. 
Maylard:    Cylinder-celled  Epithelioma  of  the  Umbilicus.     Trans.  Glasg.  Path,  and  Clin.  Soc, 

1886-91;   1892,  iii,  294. 
Morris,  R.:    Malignant  Disease  of  the  Navel  as  a  Secondary  Complication.     Verhandl.  d.  10. 

Internat.  Med.  Cong.,  1890,  Berlin,  1891,  iii.  Abth.,  vii,  122-126. 
Neveu,  v. :  Contribution  a  l'etude  des  tumeurs  malignes  secondaires  de  l'ombilic.     Paris,  1890. 
Osier,  Sir  William:    Lectures  on  the  Diagnosis  of  Abdominal  Tumors.     New  York  Med.  Jour., 

1894,  lix;  lx. 
Parker,  W. :  Excision  of  Umbilicus  for  Malignant  Disease.     Arch.  Clin.  Surg.,  New  York,  1876- 

77,  i,  71. 
Pernice,  L. :  Die  Nabelgeschwiilste,  Halle,  1892. 

Quenu  et  Longuet:  Du  Cancer  secondaire  de  l'ombilic.     Revue  de  Chir.,  1896,  xvi,  97. 
Sollier,  Paul  Henri:  See  Dejerine. 
Stori,  T.:  Contributo  alio  studio  dei  tumori  dell'ombelico.     Lo  Sperimentale,  Archivio  di  biologia 

normale  e  patologia,  1900,  liv,  25. 
Tillaux  and  Barraud:  Epithelioma  de  l'ombilic,  developpe  aux  depens  d'un  diverticule  intestinal; 

omphalectomie;  guerison.     Ann.  de  Gyn.,  Paris,  1887,  xxvii,  401. 
Villar,  F. :  Tumeurs  de  l'ombilic.     These  de  Paris,  1886. 
Wagner:   Abtragung  eines  carcinomatosentarteten  Nabels.     Med.  Jahrb.  d.  k.  k.  oster.  Staates, 

Wien,  1839,  N.  F.,  xviii,  585-589. 


CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO  CARCINOMA  OF  THE  STOMACH. 

In  27  cases  we  have  found  fairly  conclusive  evidence  that  the  umbilical  growth 
was  secondary  to  carcinoma  of  the  stomach. 

Age.  —  In  23  of  these  we  have  definite  data  as  to  the  age  of  the  patient.  The 
youngest  patient  was  twenty-six,  the  oldest  seventy-two,  years  of  age. 

26  years  old 1  case 

Between  30  and  40 1      " 

"       40  and  50 4  cases 

"       50  and  60 , 10     " 

"       60  and  70 5      " 

"       70  and  80 2     " 

From  the  above  it  will  be  seen  that  the  age  distribution  corresponds  to  that  in 
which  carcinoma  of  the  stomach  is  usually  found. 

Sex.  —  Of  the  27  cases,  data  as  to  the  sex  are  given  in  23.  Ten  of  the  patients 
were  men  and  13  were  women,  indicating  that  men  are  nearly  equally  liable  to  this 
affection. 

Trauma.  —  Occasionally,  as  in  the  cases  reported  by  Attimont,  Burkhart, 
and  Wulckow,  and  in  my  own  Case  G.,  the  patient  attributed  the  umbilical  lesion 
to  an  injury.  Attimont's  patient  dated  her  symptoms  from  the  time  she  had  hurt 
her  abdomen  on  the  edge  of  a  tub.  Burkhart's  patient  noticed  an  umbilical  nodule 
four  months  after  her  abdomen  had  been  accidentally  and  forcibly  compressed; 
Wulckow's  patient,  as  he  was  going  home  on  a  dark  night,  struck  his  abdomen 
against  a  stony  projection  and  complained  from  that  time  on.     My  patient,  shortly 


CARCINOMA    OF    THE    UMBILICUS.  413 

before  the  umbilical  growth  was  noticed,  had  been  struck  in  his  umbilical  region 
by  a  boot,  which  was  probably  not  unusual  for  him,  as  he  kept  a  shoe-store. 

Gastric  Symptoms.  —  In  about  two-thirds  of  the  cases  symptoms 
suggestive  of  deranged  digestion  were  noted.  In  some  there  was  loss  of  appetite, 
in  others  indigestion  accompanied  by  more  or  less  epigastric  pain;  some  vomited 
food,  and  in  one  case  at  least  the  vomitus  contained  blood. 

A  deep-seated  tumor  in  the  pyloric  region  was  detected  in  several  cases,  and  the 
condition  was  so  clear  that  the  physician  diagnosed  cancer  of  the  stomach.  In  a 
few  cases  a  definite  enlargement  of  the  liver  was  found,  and  in  several  instances  the 
abdomen  contained  ascitic  fluid.  Quite  a  number  of  the  patients,  however,  gave 
no  gastric  symptoms  whatsoever,  but  felt  weak  and  looked  cachectic.  In  at  least 
one  case  (Valette's)  there  was  not  the  slightest  evidence  at  operation  of  any  other 
abdominal  lesion.  It  will  be  noted  that  the  umbilical  growth  was  the  size  of  a  50- 
centime  piece,  and  that  its  central  portion  was  ulcerated,  and,  moreover,  that  it  was 
firmly  fixed.  During  removal  of  the  tumor  the  abdomen  was  inspected  and  small 
peritoneal  metastases  were  found.  The  stomach,  however,  appeared  to  be  normal. 
The  patient  died  on  the  eighth  day,  and  at  autopsy  a  primary  carcinoma  was  found 
in  the  stomach. 

The  umbilical  nodule,  when  first  noted,  may  not  be  larger  than  a  grain  of  wheat. 
In  the  course  of  a  few  months  it  has  increased  in  some  cases  to  the  size  of  a  small 
nut,  in  others  to  that  of  a  chestnut.  Sometimes  it  is  first  noted  in  the  umbilical  de- 
pression; in  other  instances  in  the  umbilical  wall  or  in  the  tissues  immediately 
adjacent  to  the  umbilicus.  At  first  these  tumors  may  be  sharply  circumscribed, 
the  overlying  skin  being  free.  But  with  the  growth  of  the  nodule  the  skin  soon  be- 
comes adherent  and  the  tumor  may  show  a  bluish-violet  or  brownish-red  discolora- 
tion. The  more  prominent  portions  of  the  tumor  tend  to  become  ulcerated,  and 
may  discharge  a  serous  or  purulent  fluid  or  be  covered  with  crusts.  In  a  few  in- 
stances there  have  been  several  small  hemorrhages  from  them.  With  the  continued 
growth  of  the  nodule  the  central  portion  may  be  deeply  ulcerated,  and  surrounding 
the  ulcer  papillary  or  cauliflower-like  masses  may  form  and  the  nearby  skin  show 
considerable  infiltration,  frequently  of  an  inflammatory  character. 

In  Cannuet's  case  there  was  a  small  umbilical  hernia.  This  contained  incar- 
cerated omentum,  in  which  was  found  a  carcinomatous  nodule.  In  a  case  which  I 
have  recently  seen  (Plate  V)  the  patient  had  had  an  umbilical  hernia  for  thirty-two 
years.  A  few  months  before  coming  under  my  care  the  hernial  mass  had  become 
hard,  and  on  palpation  definite  firm  nodules  could  be  felt  scattered  throughout  it. 
At  operation  I  found  an  ovarian  tumor,  general  peritoneal  carcinosis,  and  a  markedly 
thickened  omentum.  The  portion  of  the  omentum  incarcerated  in  the  umbilical 
hernia  also  contained  carcinomatous  nodules.  The  primary  growth  in  this  case  was 
apparently  in  the  ovary. 

There  is  another  group  of  cases  presenting  a  totally  different  picture.  The 
umbilicus  may  or  may  not  be  the  seat  of  a  nodule,  but  a  slight  tumefaction  of  the 
region  is  noted.  The  swelling  increases  in  amount  and  abscess  is  suspected.  In 
some  cases  the  picture  is  that  of  an  acute  phlegmon.  On  the  supposition  that  the 
condition  was  inflammatory,  several  of  the  tumors  were  opened.  The  incision  in 
some  yielded  nothing  but  blood  and  serous  fluid;  in  others  small  foci  of  pus  were 
found.  In  a  short  time  the  supposed  inflammatory  area  would  undergo  gradual 
dissolution  or  necrosis  en  masse,  and  a  fungating  base  be  left  at  the  site  of  the 


414  THE    UMBILICUS    AND    ITS    DISEASES. 

umbilicus.  A  little  later  gas-bubbles  would  be  noted,  and  ere  long  stomach-con- 
tents would  commence  to  pass  through  the  fistulous  opening.  The  margins  of  the 
fistulous  opening  in  some  cases  were  surrounded  by  large  papillary  or  fungoid 
growths.  In  these  cases  the  carcinoma  had  not  extended  to  the  umbilicus  by  way 
of  the  suspensory  ligament,  but  by  direct  continuity.  The  carcinoma  of  the 
stomach  had  become  adherent  to  the  abdominal  wall  at  or  near  the  umbilicus,  and 
by  direct  extension  had  caused  a  gradual  disintegration  until  the  surface  of  the 
abdomen  had  been  reached. 

If  the  carcinoma  is  situated  at  or  near  the  pylorus  and  becomes  adherent  to  the 
abdominal  wall,  it  is  only  natural  that  the  attachment  should  be  in  the  umbilical 
region.  If  the  disease,  however,  be  in  another  part  of  the  stomach,  the  abdominal 
wall  may  be  attacked  at  another  point,  as  was  well  shown  in  the  following  case : 

Mrs.  B.,  seen  in  consultation  with  Dr.  Edwin  B.  Fenby  July  8,  1910.  This 
patient  had  been  seized  that  evening  with  sudden  abdominal  pain  about  an  inch 
and  a  half  above  and  to  the  left  of  the  umbilicus.  She  had  a  temperature  of  100°  F.  ; 
pulse,  116.  "When  I  saw  her,  she  was  rather  pale.  Appendicitis  was  ruled  out, 
but  some  malignant  growth  was  suspected.  She  had  a  leukocytosis  of  15,000. 
She  was  at  once  removed  to  the  hospital'  for  observation.  Ten  days  later  we  made 
an  incision  through  the  left  rectus,  and  on  cutting  down  to  the  fascia  found  some 
edema.  On  going  into  the  peritoneal  cavity  we  found  that  the  stomach  had  become 
adherent  to  the  anterior  abdominal  wall.  After  adhesions  had  been  liberated,  the 
parts  were  walled  off  as  thoroughly  as  possible,  and  a  tract  3  mm.  in  diameter  was 
found  passing  from  the  stomach  directly  to  the  abdominal  wall.  In  other  words, 
there  was  a  perforation  of  the  stomach  at  this  point.  We  gradually  loosened  the 
organs  from  the  surrounding  indurated  tissue,  which  in  some  places  was  fully  2  cm. 
thick  and  as  hard  as  gristle.  The  stomach  was  brought  out  and  was  found  to  be 
indurated  in  every  direction.  The  growth  was  a  carcinoma.  The  area  of  indura- 
tion in  the  anterior  wall  was  7  by  5  cm.,  and  just  beneath  the  point  of  perforation 
there  was  a  punched-out  area  in  the  carcinoma  2  cm.  long.  It  was  at  the  thinnest 
point  of  this  that  the  perforation  had  taken  place.  We  removed  about  half  of  the 
stomach.  The  patient  made  a  very  satisfactory  recovery,  and  for  a  year  there 
were  no  definite  signs  of  a  return  of  the  growth.  These,  however,  developed  later 
and  she  died  on  November  12,  1911. 

In  those  cases  in  which  the  disease  reaches  the  umbilicus  by  way  of  the  suspen- 
sory ligament  the  peritoneal  surface  of  the  umbilicus  is  usually  smooth,  because  the 
lymphatics  are  extraperitoneal.  On  section  an  intact  carcinomatous  nodule  of  the 
umbilicus  does  not  resemble  cancer,  but  we  find  what  looks  like  a  diffuse  fibrous 
thickening,  and  one  can  hardly  realize  that  it  is  fairly  riddled  with  glands.  This 
fibrous  appearance  is  well  seen  in  Fig.  184,  B  (p.  424),  and  Fig.  190  (p.  443). 
Where  ulceration  exists,  however,  the  true  character  of  the  growth  is  more  mani- 
fest. On  histologic  examination  the  tumor  is  found  to  consist  of  fibrous  tissue 
with  myriads  of  carcinomatous  glands  scattered  throughout  it.  The  gland  type  is 
identical  with  that  found  in  the  original  gastric  tumor,  and  where  ulceration  has 
occurred,  the  usual  picture  of  gland  disintegration,  together  with  polymorphonu- 
clear leukocytes  and  small-round-cell  infiltration,  is  noted  on  the  surface. 

Treatment.  — -If  a  patient  has  given  definite  signs  of  carcinoma  of  the 
stomach,  by  the  time  an  umbilical  nodule  has  developed  the  malignant  process  has 
become  so  wide-spread  that  operative  interference  is  of  no  avail.     In  those  cases  in 


CARCINOMA    OF    THE    UMBILICUS.  415 

which  the  cancer  has  extended  to  the  abdominal  wall  by  continuity  and  has  broken 
down,  causing  a  gastro-umbilical  fistula,  operation  is  out  of  the  question. 

There  are  a  certain  number  of  cases,  however,  in  which,  even  when  a  secondary 
abdominal  nodule  exists,  gastric  symptoms  are  lacking.  Here  the  surgeon  will 
naturally  remove  the  umbilical  growth  in  the  hope  that  it  may  be  a  primary  lesion. 
In  all  such  cases,  when  the  abdomen  is  opened,  a  careful  survey  of  the  stomach  and 
abdominal  contents  should  be  made  to  determine  if  any  visceral  carcinoma  exists. 

Prognosis.  —  Where  an  umbilical  carcinoma  is  secondary  to  carcinoma  of 
the  stomach,  practically  all  the  patients  speedily  succumb. 

Cases  of  Carcinoma  of  the  Umbilicus  Secondary  to  Cancer  of  the  Stomach. 

In  the  majority  of  the  cases  here  detailed  the  diagnosis  is  certain,  as  proved  at 
operation  or  at  autopsy.  In  a  few  of  the  cases  such  absolute  proof  was  wanting, 
but  the  clinical  picture  strongly  suggested  the  stomach  as  the  source  of  the  primary 
tumor. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma 
of  the  Stomach.  —  Attimont's*  patient  was  a  woman  fifty-three  years  of 
age.  She  had  enjoyed  good  health  until  three  months  before  he  saw  her,  and  dated  ■ 
her  gastric  symptoms  from  the  time  she  hit  her  abdomen  on  the  edge  of  a  tub.  On 
palpation  no  internal  tumor  could  be  found,  but  at  the  umbilicus  were  two  small 
nodules  the  size  of  grains  of  wheat.  At  the  end  of  two  months  the  patient  returned 
emaciated.  The  nodules  at  the  umbilicus  had  increased  in  size,  one  being  as  large 
as  a  small  walnut.  It  was  hard,  and  the  overlying  skin  was  adherent.  The  umbili- 
cal mass  was  removed  and  proved  to  be  an  adenocarcinoma. 

Autopsy  at  a  later  date  showed  carcinoma  of  the  lesser  curvature  of  the  stomach, 
with  secondary  nodules  on  the  surface  of  the  liver  and  uterus  and  cancerous  masses 
between  the  folds  of  the  suspensory  ligament. 

Cancer  of  the  Stomach;  Gastro-abdominal  Fistula. f 
— A  woman,  forty-nine  years  of  age,  complained  of  epigastric  pain,  difficult  diges- 
tion, and  frequent  vomiting.  Blood  had  never  been  noted  in  the  vomited  material 
or  in  the  stools.  On  palpation  an  ill-defined  tumor  was  found  in  the  epigastric 
region  which  was  painful  on  pressure.  Cancer  of  the  stomach  was  diagnosed. 
Some  time  after  the  patient  entered  the  hospital  she  had  fever  at  night.  The  tumor 
rapidly  increased  in  size.  The  abdominal  wall  became  a  little  red,  was  painful  on 
pressure,  and  fluctuation  was  detected.  On  making  an  opening  with  the  bistoury 
odorless  pus  escaped.  A  sound  could  be  passed  inward  for  5  or  6  cm.  The  fever 
disappeared  and  the  patient  ate  without  vomiting  or  pain.  A  month  later  the  skin 
around  the  incision  was  thinner,  reddened,  and  an  area  of  ulceration  the  size  of  a 
five-franc  piece  existed.  In  the  depression  were  fungoid  masses  which  gave  off 
a  fecal  odor.  Two  weeks  later  all  trace  of  the  umbilicus  had  disappeared  and  there 
was  an  area  of  ulceration  as  large  as  the  palm  of  the  hand,  and  three  fungoid  masses, 
forming  a  tumor  the  size  of  a  fist,  presented.  The  discharge  was  so  fetid  that  the 
patient  was  isolated.  Gas  and  particles  of  stomach-contents  escaped.  The 
mushroom   growths  increased  rapidly  and    broke   down    easily.      Hemorrhages 

*  Attimont,  A.:  Remarques  sur  le  cancer  de  l'ombilic.  Gaz.  med.  de  Nantes,  1887-88,  vi, 
137;  149. 

f  Auger,  M.  G.:  Cancer  de  l'estomac  fistule  gastro-abdominale.  Bull.  Soc.  anat.  de  Paris, 
1875,  i,  708. 


416  THE    UMBILICUS    AND    ITS    DISEASES. 

resulted,  which  were  controlled  with  difficulty.  The  patient  became  very  cachectic, 
and  died  two  weeks  later. 

At  autopsy  the  abdomen  contained  clear  yellow  fluid.  The  intestines  were 
small  in  caliber,  but  not  adherent.  The  anterior  part  of  the  stomach  was  adherent 
to  the  ulcerated  abdominal  wall.  The  opening  was  near  the  pylorus;  the  area 
round  it  was  hard  and  infiltrated.  The  subcutaneous  abdominal  tissue  was  ne- 
crotic. The  right  lobe  of  the  liver  contained  cancerous  masses.  In  this  case  the 
carcinoma  of  the  stomach  had  become  adherent  to  the  umbilicus  and  the  open- 
ing between  the  stomach  and  the  umbilicus  had  resulted. 

Carcinoma  of  the  Stomach  with  Perforation  of  the 
Abdominal  Wall.*  —  The  patient  was  a  weakly  woman,  fifty-two  years  of 
age,  and  the  mother  of  17  children.  In  the  spring  she  had  complained  of  pain  in 
the  abdomen,  and  in  July  had  had  to  give  up  work.  She  was  very  anemic  and 
wasted.  In  August  she  had  had  severe  colicky  pains  in  the  region  of  the  spleen; 
in  September  these  had  migrated  to  the  umbilical  region.  At  this  time  there  could 
be  felt  a  tumor  the  size  of  a  fist  deep  in  that  region.  The  tumor  descended  until  it 
lay  behind  the  umbilicus,  forming  a  mass  about  5  inches  in  diameter,  with  the  um- 
bilicus in  the  center.  It  became  softer,  and  a  few  days  later  a  small  area  sloughed, 
and  the  stomach-contents  escaped.  The  opening  rapidly  increased  in  size  and 
the  patient  soon  died.  The  growth  was  a  carcinoma  of  the  stomach  which  had 
opened  near  the  umbilicus. 

Carcinoma  of  the  Umbilicus  Probably  Secondary 
to  Carcinoma  of  the  Stomach. f  —  A  delicate,  poorly  nourished 
woman,  fifty-nine  years  of  age,  entered  Bergmann's  clinic.  Some  time  before,  her 
abdomen  had  been  accidentally  compressed,  and  four  months  later  she  had  noticed 
a  painless  but  hard  nodule  at  the  umbilicus.  The  skin  covering  it  was  smooth. 
Three  months  later  the  tumor  was  the  size  of  a  hazel-nut.  On  examination  the 
umbilicus  was  elevated.  The  tumor  was  the  size  of  a  two-mark  piece  and  could  be 
sharply  outlined.  The  surface  was  very  red  and  nodular,  and  suggested  dense 
granulation  tissue.  It  secreted  pus.  Operation  was  not  advised,  but  was  insisted 
upon  by  the  patient.  She  left  the  hospital  before  any  local  return  had  occurred. 
The  growth  was  a  glandular  carcinoma  and  probably  secondary  to  carcinoma  of  the 
stomach. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma 
of  the  Stomach. t  —  A  farmer,  aged  seventy-two,  for  six  months  had 
been  complaining  of  gastric  disturbances.  Ten  weeks  before  coming  under  obser- 
vation he  had  noticed  a  moistness  at  the  umbilicus  and  a  discharge  of  a  tarry- 
looking,  brownish  secretion.  Later  there  had  been  ulceration,  which  had  gradually 
increased.  The  patient  was  well  nourished  and  strong.  At  the  umbilicus  was  an 
irregular  ulceration  the  size  of  a  two-mark  piece.  It  was  hard  and  seemed  unat- 
tached. At  operation  it  was  necessary  to  remove  the  ligament um  teres  to  the 
liver.  The  patient  died  one  month  after.  A  carcinoma  the  size  of  a  three-mark 
piece  was  found  near  the  pylorus;  it  was  adherent  to  the  liver,  and  in  the  liver 
diffuse  carcinomatous  infiltration  was  present. 

*  Balluff:    Magenkrebs,  Erweichung  unci  Aufbruch  desselben  durch  die  allgemeinen  Bauch- 
decken,  Magenfistel.     Correspondenzbl.  des  Wiirtemberg.  arztl.  Vereins,  Stuttgart,  1854,  xxiv,  37. 
t  Burkhart:  Ueber  den  Nabelkrebs.     Inaug.  Diss.,  Berlin,  1889. 
X  Burkhart:   Op.  cit. 


CARCINOMA    OF   THE   UMBILICUS.  417 

Carcinoma  of  the  Liver  with  Carcinoma  of  the  Omen- 
tum; Incarcerated  Umbilical  Hernia.' — ■  Cannuet*  reported 
the  case  of  a  patient  with  carcinoma  of  the  liver  probably  secondary  to  carcinoma 
of  the  stomach.  There  was  an  umbilical  hernia  containing  incarcerated  omentum, 
and  in  this  incarcerated  omentum  was  a  cancerous  nodule. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma 
of  the  Stomach,  f  — -A  man,  sixty-three  years  of  age,  had  had  pain  in  the 
abdomen,  complained  of  indigestion,  and  later  had  noticed  a  tumefaction  at  the 
umbilicus.  He  had  diarrhea  and  vomiting  and  a  supposed  abscess  of  the  abdominal 
wall.  This  was  opened  and  bloody  fluid  escaped.  Later  there  was  the  character- 
istic fetid  cancerous  discharge  from  the  umbilicus.  At  autopsy  a  carcinoma  of  the 
pylorus  was  found  adherent  to  the  umbilical  tumor. 

Carcinoma  of  the  Umbilicus  Secondary  to  Cancer 
of  the  Stomach. J  —  In  a  woman,  twenty-six  years  of  age,  a  fistula  devel- 
oped at  the  umbilicus.  There  was  no  vomiting,  but  emaciation.  Just  above  the 
umbilical  cicatrix  was  a  reddening.  The  skin  was  distended,  hot,  and  painful  and 
serous  or  purulent  fluid  escaped  from  the  opening.  At  autopsy  cancer  of  the 
pyloric  region  was  found.  On  the  outer  surface  of  the  pylorus  were  cancerous 
vegetations.  These  had  become  adherent  to  the  abdominal  wall;  suppuration  had 
followed,  and  an  opening  had  developed  at  the  umbilicus. 

Carcinoma  of  the  Umbilicus  Secondary  to  Cancer 
of  the  Stomach.  —  Fischer  §  operated  on  a  woman  fifty-two  years  of  age 
who  had  a  carcinomatous  tumor  of  the  umbilicus  which  had  extended  as  far  as  the 
interior  of  the  abdomen.  On  opening  the  abdomen  he  discovered  that  the  anterior 
part  of  the  stomach  was  perforated  and  transformed  into  a  large  carcinomatous 
ulcer,  which  penetrated  directly  into  the  transverse  colon.  The  patient  had  never 
manifested  any  gastric  symptoms.  Fischer  removed  the  entire  anterior  portion  of 
the  stomach  and  the  diseased  colon.  The  patient  made  a  good  recovery,  but  devel- 
oped other  stomach  symptoms  and  died  five  months  later. 

Carcinoma  of  the  Umbilicus,  Secondary.  1 1  ■ — -A  woman, 
fifty  years  of  age,  had  had  a  warty,  nodular  growth  at  the  umbilicus  for  two  or 
three  months  and  was  not  in  good  health.  No  abdominal  lesions  being  noted, 
Hutchinson  made  an  elliptic  incision  and  removed  the  growth.  It  extended  to  but 
had  not  invaded  the  peritoneum.  Two  months  later  there  was  a  nodular  thicken- 
ing of  the  liver,  great  irritability  of  the  stomach,  and  the  patient  died  four  months 
after  operation.  Hutchinson  thought  that  the  umbilical  growth  was  secondary  to 
that  in  the  liver.  In  two  other  of  his  cases,  he  says,  a  carcinoma  of  the  umbilicus 
had  developed  secondarily  to  a  growth  in  the  liver. 

[Of  course,  the  majority  of  the  cases  of  cancer  of  the  liver  are  secondary  to  those 
of  the  stomach.— T.  S.  C] 

Carcinoma  of  the  Umbilicus  Secondary  to  Cancer 
of  the  Stomach.**  —  A  man,  forty-four  years  of  age,  gave  a  history  of  vom- 

*  Cannuet:  Bull.  Soc.  anat.  de  Paris,  1852,  xxvii,  274. 

f  Codet  de  Boisse:  Tumeurs  de  l'ombilic  chez  l'adulte.     These  de  Paris,  1883,  No.  311. 
X  Feulard:  Fistule  ombilicale  et  cancer  de  l'estomac.     Arch.  gen.  de  med.,  1887,  7.  s.,  xx,  158. 
§  Fischer  (Breslau) :  Resection  de  l'estomac.     La  Semaine  med.,  Paris,  1888,  viii,  134. 
||  Hutchinson,  Jonathan:  Arch,  of  Surgery,  1893,  iv,  153  (1  pi.). 
**  Largeau,  R.:  Cancer  de  l'ombilic.     Bull.  Soc.  anat.  de  Par.,  1884,  lix,  210-212. 
28 


418  THE    UMBILICUS   AND   ITS   DISEASES. 

iting  and  loss  in  weight.  At  the  umbilicus  was  a  tumor  5  cm.  in  diameter.  Its 
central  portion  was  ulcerated  and  surrounded  by  a  zone  of  induration.  At  death 
the  growth  was  found  extending  to  the  peritoneal  surface,  but  there  was  no  adhesions. 
The  patient  had  cancer  of  the  stomach,  which  had  extended  to  the  liver.  There 
were  numerous  other  Secondary  nodules. 

Carcinoma  of  the  Umbilicus  Probably  Secondary  to 
Cancer  of  the  Stomach  or  Liver.  —  Ledderhose,*  after  giving  a 
survey  of  the  literature,  reports  a  case  communicated  to  him  by  A.  Cahn.  L., 
fifty-eight  years  of  age,  complained  of  gradually  increasing  lack  of  appetite  and  of 
the  development,  a  few  months  later,  of  edema  of  the  lower  extremities  and  varicose 
veins  in  the  leg.  Still  later  the  scrotum  and  the  abdominal  wall  became  edematous 
and  there  was  also  ascites  with  complete  loss  of  appetite  and  intestinal  obstruction. 
At  the  umbilicus  was  a  hard,  semicircular  nodule.  By  deep  ballottement,  enlarge- 
ment of  the  hardened  liver  could  be  made  out.  A  provisional  diagnosis  of  carci- 
noma of  the  liver  with  peritonitis  was  made.  No  microscopic  examination  is  given. 
In  all  probability  the  umbilical  growth  was  secondary  to  a  carcinoma  of  the  stomach 
with  implication  of  the  liver.  Ledderhose  follows  this  by  two  other  observations; 
in  none  of  the  cases,  however,  was  any  autopsy  made. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma 
of  the  Stomach. f  —  A  man,  forty-five  years  of  age,  gave  a  history  of 
vomiting  for  a  year.  He  was  well  nourished  and  of  good  color,  but  had  lost  24 
pounds.  At  the  upper  and  left  side  of  the  umbilicus  was  a  small  tumor  the  size  of  a 
bean;  the  overlying  skin  was  free.  In  two  weeks  the  tumor  had  become  adherent 
to  the  skin  and  had  increased  in  size.  Two  months  later  the  abdomen  was  dis- 
tended with  ascitic  fluid,  and  the  patient  died  soon  after  the  fluid  had  been  removed. 

Autopsy  showed  carcinoma  of  the  lesser  curvature  of  the  stomach  and  com- 
pression of  the  portal  vein;  no  involvement  of  the  liver  was  found.  No  micro- 
scopic examination  of  the  abdominal  tumor  is  recorded. 

Umbilical  Fistula  Due  to  Latent  Cancer  of  the  Stom- 
ach. —  Monod's  t  patient  was  a  woman  sixty-six  years  of  age.  She  was  cachetic, 
but  had  had  no  vomiting.  At  the  umbilicus  was  a  fistulous  opening  of  recent  date. 
A  diagnosis  of  latent  cancer  of  the  stomach  was  made.  At  autopsy  in  the  region 
of  the  umbilicus  Monod  found  a  compact  mass  consisting  of  the  stomach,  liver, 
transverse  colon,  and  duodenum.  The  lesser  curvature  of  the  stomach  was  adher- 
ent to  the  liver.  The  anterior  surface  of  the  stomach  was  involved  in  the  cancer, 
which  extended  to  the  posterior  surface;  the  fistulous  opening  reached  the  umbili- 
cus. The  transverse  colon  communicated  by  an  oblique  opening,  measuring  5  x 
6  cm.,  with  a  pocket  formed  by  the  stomach  and  the  left  lobe  of  the  liver. 

Cancer  of  the  Umbilicus  Secondary  to  Cancer  of  the 
Pylorus. §  — -A  woman,  seventy  years  of  age,  came  with  a  diagnosis  of  cancer 
of  the  pylorus.  Six  months  from  the  beginning  of  her  symptoms  she  had  begun 
to  have  pain  at  the  umbilicus  and  noticed  a  small  lump  there.     This  became  very 

*  Ledderhose :  Chirurgische  Erkrankungen  des  Nabels.  Deutsche  Chirurgie,  1890,  Lief. 
45  b. 

f  Mirallie:  Reported  by  Attimont. 

t  Monod:  Fistule  Ombilicale;  cancer  latent  de  l'estomac.  Bull.  Soc.  anat.  de  Paris,  1877, 
lii,  38. 

§  Morris,  Robert :  Lectures  on  Appendicitis  and  Notes  on  Other  Subjects,  1895,  95. 


CARCINOMA    OF    THE    UMBILICUS.  419 

hard,  was  about  as  large  as  a  chestnut,  bluish  red  in  color,  and  had  a  smooth  sur- 
face, which  was  somewhat  ulcerated  and  discharged  a  little  straw-colored  serum. 
Morris  removed  the  diseased  umbilicus  and  found  that  it  was  not  in  contact  with 
anything  but  normal  structures.  The  patient  died  two  months  later  with  the 
ordinary  symptoms  of  cancer  of  the  pylorus.  No  autopsy,  however,  was  permitted. 
The  umbilical  growth  was  an  adenocarcinoma. 

Cancer  of  the  Pylorus;  Secondary  Growth  at  the 
Umbilicus.  —  Morris  *  cites  an  extract  from  a  letter  from  Dr.  Grinnell,  of 
Burlington,  Vermont.  The  patient  was  a  man  sixty-eight  years  of  age  who  had 
symptoms  of  cancer  of  the  pylorus.  Eight  months  before  death  the  umbilicus 
became  hard  and  painful  and  there  was  a  malodorous  discharge  from  it.  Five 
months  before  death  enlargement  of  the  liver  was  noted;  the  death  was  caused  by 
cancer  of  the  liver,  as  determined  at  autopsy. 

Carcinoma  of  the  Umbilicus  Probably  Secondary 
to  Cancer  of  the  Stomach,  f  —  Case  109  was  a  personal  communica- 
tion received  by  Pernice  from  R.  Volkmann.  The  man  was  tapped  on  account  of 
the  presence  of  ascitic  fluid,  which  proved  to  be  hemorrhagic  in  character.  After 
the  removal  of  the  fluid  a  tumor  could  be  palpated.  The  umbilicus,  stomach,  and 
liver  region  were  involved,  and  at  the  umbilicus  were  adhesions  to  the  skin.  The 
patient  died  without  operation  and  no  autopsy  was  allowed. 

Secondary  Carcinoma  of  the  Umbilicus. J  — A  woman, 
aged  fifty-nine,  entered  the  Frauenklinik  in  Breslau.  About  six  or  nine  months 
before,  she  had  noticed  below  the  umbilicus  a  small,  hard  nodule,  that  gave  rise  to 
little  trouble  and  did  not  interfere  with  her  work.  She  suffered  from  lack  of  appe- 
tite, vomiting,  and  constipation.  The  nodule  grew  rapidly  and  commenced  to  give 
trouble.  The  umbilicus  became  reddened  and  inflamed.  On  admission  she  looked 
frail  and  cachectic.  The  swelling  at  the  umbilicus  had  extended  to  the  surrounding 
parts,  and  the  tissue  was  very  hot  and  painful.  On  examination  there  could  be  felt 
in  the  depth  a  tumor  the  size  of  an  ostrich's  egg.  On  both  sides  the  tumor  ex- 
tended 5  cm.  from  the  umbilicus  and  could  be  sharply  outlined.  About  3  cm.  above 
the  umbilicus  were  several  other  fluctuating  nodules.  An  exploratory  operation  was 
made,  and  three  small  abscesses,  containing  purulent,  smeary  masses  were  removed. 
The  abdomen  was  opened,  and  the  tumor  was  found  to  involve  the  stomach. 
Resection  of  the  stomach  was  done,  and  the  patient  died  of  shock.  In  this  case 
there  was  a  primary  carcinoma  of  the  stomach  and  a  secondary  growth  at  the 
umbilicus.  It  will  be  noted  that  the  primary  tumor  in  the  beginning  had  given 
hardly  any  symptoms. 

Secondary  Carcinoma  of  the  Umbilicus. §  —  This  case  was 
reported  from  the  Universitatsklinik  in  Halle.  A  man,  fifty-eight  years  of  age,  had 
been  strong  and  healthy  until  he  began  to  complain  of  pain  in  the  abdomen  and 
of  a  brownish  vomitus.  Later  he  had  pain  in  the  region  of  the  umbilicus  and  then 
a  nodule  was  detected.  The  patient  on  admission  was  very  feeble,  and  the  skin 
had  a  jaundiced  tint.  The  umbilicus  was  somewhat  distended  by  a  nodule  the 
size  of  a  10-pfennig  piece.  It  was  very  hard  and  painful,  brownish  red,  and  on  the 
surface  slightly  ulcerated.  In  this  case  there  was  probably  a  carcinoma  of  the 
stomach  with  secondary  carcinoma  at  the  umbilicus.     Operation  was  refused. 

*  Morris:  Op.  cit.,  114.  f  Pernice:   Die  Nabelgeschwulste,  Halle,  1892. 

t  Pernice:   Op.  cit.,  obs.  110.  §  Pernice:  Op.  cit.,  obs.  123. 


420  THE    UMBILICUS    AND    ITS    DISEASES. 

Carcinoma  of  the  Umbilicus  Secondary  to  Cancer 
of  the  Stomach.*  —  For  about  a  year  a  woman,  sixty-two  years  of  age, 
had  had  symptoms  of  cancer  of  the  stomach.  For  four  months  she  had  noticed  a 
hardening  at  the  umbilicus.  This  was  prominent;  the  skin  was  reddened,  the 
surface  of  the  tumor  uneven  and  very  dense.  It  was  sharply  defined  and  showed 
no  ulceration. 

Carcinoma  of  the  Umbilicus  Secondary  to  Abdominal 
Carcinoma. f  —  A  woman,  forty  years  of  age,  suffered  from  a  malignant 
disease  in  the  abdomen  and  had  been  frequently  tapped.  At  autopsy  carcinoma 
of  the  liver,  omentum,  and  peritoneal  surfaces  of  the  intestine  was  found,  and  the 
uterus  and  ovaries  formed  one  mass.  At  the  umbilicus  was  a  circumscribed  tumor 
the  size  of  the  last  phalanx  of  the  thumb,  looking  like  an  umbilical  hernia.  This 
was  also  a  carcinoma,  evidently  secondary  to  the  abdominal  tumor,  which  had 
probably  originated  in  the  stomach. 

Carcinoma  of  the  Umbilicus  Secondary  to  Cancer  of 
the  Stomach.  —  Tillmannsi  said  he  saw  a  case  of  carcinoma  of  the  stomach 
with  a  secondary  growth  at  the  umbilicus. 

Secondary  Carcinoma  of  the  Umbilicus. §  — -A  farmer, 
aged  fifty-two,  for  two  months  had  noticed  an  enlargement  at  the  umbilicus  which 
had  increased  rapidly  in  size  and  become  ulcerated.  The  patient  was  slightly 
emaciated.  The  inguinal  glands  were  enlarged.  Peritoneal  carcinosis,  which  had 
probably  originated  from  the  stomach,  was  found  at  operation.  No  microscopic 
examination  was  made. 

Cancer  of  the  Umbilicus  Secondary  to  Cancer  of  the 
Cardiac  End  of  the  Stomach.  |j  —  The  patient,  fifty  years  of  age, 
was  admitted  to  the  service  of  Damaschino.  Cancer  of  the  stomach  could  be 
definitely  made  out.  Later  on,  just  beneath  the  umbilicus,  one  could  feel  with  the 
ends  of  the  fingers  a  hard  tumor  occupying  the  lower  portion  of  the  epigastric 
region.  This  tumor  had  a  regular  surface  and  presented  the  characteristics  of  a 
secondary  neoplasm.  Still  later,  at  the  umbilical  cicatrix,  there  appeared  a  small, 
violet-colored  tumor.  This  was  covered  over  with  a  delicate  crust.  Microscopic 
examination  showed  that  the  tumor  of  the  stomach  and  omentum,  the  abdominal 
glands,  and  the  growth  in  the  umbilical  cicatrix  were  of  precisely  the  same  type 
of  cancer. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carci- 
noma of  the  Stomach.- — ■  The  report  of  the  case  was  communicated  to 
Villar**  by  Broussolle.  X.  entered  the  service  of  Professor  Le  Fort  in  1885.  There 
had  been  no  digestive  disturbances.     The  patient  had  come  to  Paris  to  consult  a 

*  Schlesinger :  Die  Bedeutung  cler  Nabelmetastasen  ftir  die  Diagnose  abdomineller  Neo- 
plasmen.     Wien.  med.  Wochenschr.,  1911,  No.  8,  519. 

f  Storer:  Circumscribed  Tumor  of  the  Umbilicus  Closely  Simulating  Umbilical  Hernia,  etc. 
Boston  Med.  and  Surg.  Join-.,  1864,  lxx,  73. 

X  Tillmanns,  H.:  Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring 
(Ectopia  ventriculij,  und  iiber  sonstige  Geschwulste  und  Fisteln  des  Nabels.  Deutsche  Zeitschr. 
f.  Chir.,  1882-83,  xviii,  161. 

§  Tisserand:  A  propos  de  deux  cas  de  cancer  secondaire  de  l'ombilic.  La  Loire  med.,  St. 
Etienne,  1906,  xxv,  131. 

||  Villar:  Tumeurs  de  l'ombilic.     These  de  Paris,  1886,  obs.  79. 

**  Villar:   Op.  cit.,  obs.  85. 


CARCINOMA    OF    THE    UMBILICUS.  421 

surgeon  on  account  of  a  vegetative,  ulcerating  tumor  situated  in  the  umbilical 
region. 

On  admission  to  the  hospital  he  was  very  feeble,  and  this  feebleness  was  attrib- 
uted to  the  fatigue  of  the  journey.  In  the  epigastric  region  and  encroaching  on  the 
umbilicus  was  a  vegetating  tumor  which  was  ulcerating  and  bled.  At  first  sight  it 
appeared  to  be  a  phlegmon,  but  on  careful  examination  was  found  to  present  special 
characteristics.  Some  time  afterward  cancerous  nodules  appeared  in  the  liver. 
At  autopsy  cancer  of  the  pylorus  was  found  and  cancerous  masses  of  the  liver 
and  plaques  of  carcinoma,  which  occupied  the  umbilicus  and  a  certain  portion  of 
the  anterior  abdominal  wall. 

Carcinoma  of  the  Umbilicus  Secondary  to  Latent 
Carcinoma  of  the  Stomach.  —  Valette*  gives  a  list  of  the  cases  of 
primary  and  secondary  carcinoma  of  the  umbilicus,  and  then  cites  the  history  of  a 
woman,  sixty-one  years  old,  who  entered  the  hospital  on  August  16,  1896.  In 
March  of  the  same  year  she  had  noticed  a  small  lump  at  the  umbilicus.  Later 
this  had  become  painful,  in  some  weeks  had  reached  the  size  of  a  large  nut,  and 
ulcerated. 

On  admission  the  umbilical  depression  was  found  replaced  by  an  elevation  of 
the  skin  with  an  ulceration  in  the  center  and  fungus-like  margins.  The  growth  was 
the  size  of  a  50-centime  piece  (about  2  cm.  in  diameter).  The  ulceration  had 
extended  to  the  aponeurosis  and  the  tumor  was  fixed.  The  inguinal  glands  were  not 
enlarged.  The  question  arose  as  to  whether  the  growth  was  primary  or  secondary. 
The  patient  gave  no  history  of  stomach  trouble  and  had  had  no  vomiting,  but  the 
appetite  was  slightly  diminished  and  she  had  lost  weight  in  the  last  six  months. 
At  operation  the  peritoneal  surface  of  the  umbilicus  was  found  smooth.  There 
were  small  metastases  in  the  peritoneum.  The  stomach  was  apparently  normal. 
The  patient  died  on  the  eighth  day.  At  autopsy  an  adenocarcinoma  of  the  stomach 
was  found.  The  growths  in  the  abdomen  and  at  the  umbilicus  were  similar  to  that 
in  the  stomach  and  were  evidently  secondary.  This  case  demonstrates  very  clearly 
the  fact  that  a  malignant  growth  in  the  stomach  may  be  unrecognizable  during 
life,  and  be  detected  only  at  autopsy. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carci- 
noma of  the  Stomach. f  —  The  patient  was  a  man,  thirty-three  years  of 
age,  of  strong  build.  When  going  home  one  dark  night  he  struck  his  abdomen  in 
the  region  of  the  stomach  against  a  stony  projection  and  was  never  well  afterward. 
Early  next  year  he  consulted  his  physician  for  indigestion.  In  the  fall  of  the  same 
year  he  noticed  that  the  umbilicus  was  inflamed,  but  there  was  no  pain.  When 
seen  by  Wulckow  the  umbilicus  was  slightly  raised  above  the  surrounding  skin  and 
was  reddened.  Along  the  margins  were  rough  excrescences,  and  where  the  skin 
was  gone  the  surface  was  moist.  The  entire  mass  was  the  size  of  a  large  plum. 
The  skin  around  the  umbilicus  was  reddened  over  an  area  the  size  of  a  two-thaler 
piece  (about  6  cm.  in  diameter).  The  growth  could  be  lifted  up  from  the  under- 
lying abdominal  contents.  The  patient  died  of  hemorrhage  of  the  stomach.  At 
autopsy  carcinoma  was  found  in  the  stomach  and  at  the  umbilicus.  The  umbilical 
growth  was  in  all  probability  secondary  to  that  in  the  stomach. 

*  Valette:  Contribution  a.  1' etude  du  cancer  secondaire  de  l'ombilic.  These  de  Paris,  1898, 
No.  550. 

f  Wulckow:  Beitrag  zur  Casuistik  der  Xabelneubildungen.  Berlin,  klin.  Wochenschr.,  1875, 
xii,  533. 


422  THE    UMBILICUS    AND    ITS    DISEASES. 


LITERATURE  CONSULTED  ON  CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO 

CARCINOMA  OF  THE  STOMACH. 

Attimont,  A. :  Remarques  sur  le  cancer  de  I'ombilic.    Gaz.  med.  de  Nantes,  1887-88,  vi,  137;  149. 
Auger,  M.  G.:   Cancer  de  l'estomac,  fistule  gastro-abdominale.  Bull.  Soc.  anat.  de  Paris,  1875, 

1,  70S. 
Balluff:   Magenkrebs.  Erweichung  und  Aufbruch  desselben  durch  die  allgemeinen  Bauchdecken, 

Magenfistel.     Med.    Correspondenzbl.   des    Wurtemberg.   arztl.   Vereins,   Stuttgart,    1854, 

xxiv,  37. 
Burkhart,  O.:  Ueber  den  Nabelkrebs.     Inaug.  Diss.,  Berlin,  1889. 
Cannuet:  Bull.  Soc.  anat.  de  Paris,  1852,  xxvii,  274. 

Codet  de  Boisse:  Tumeurs  de  I'ombilic  chez  l'adulte.     These  de  Paris,  1883,  No.  311. 
Feulard,  H.:  Fistule  ombilicale  et  cancer  de  l'estomac.     Arch.  gen.  de  med.,  1887,  7.  ser.,  xx,  158. 
Fischer:  Resection  de  l'estomac.    La  Semaine  med.,  Paris,  1888,  viii,  134. 

Hutchinson,  J. :  Carcinoma  of  the  Umbilicus,  Secondary.     Arch,  of  Surgery,  1893,  iv,  153  (1  pi.). 
Largeau,  R. :  Cancer  de  I'ombilic.     Bull.  Soc.  anat.  de  Paris,  1884,  lix,  210-212. 
Ledderhose,  G. :  Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Mirallie:  Reported  by  Attimont. 
Monod,  E.:  Fistule  ombilicale;  cancer  latent  de  l'estomac.     Bull.  Soc.  anat.  de  Paris,  1877,  lii, 

38.' 
Morris,  Robert  T. :  Lectures  on  Appendicitis  and  Notes  on  Other  Subjects,  1895,  95. 
Pernice,  L. :  Die  Nabelgeschwulste,  Halle,  1892. 
Schlesinger:    Die  Bedeutung  der  Nabelmetastasen  fur  die  Diagnose  abdomineller  Neoplasmen. 

Wien.  med.  Wochenschr.,  1911,  No.  8,  519. 
Storer,  H.  R. :    Circumscribed  Tumor  of  the  Umbilicus  Closely  Simulating  Umbilical  Hernia, 

etc.     Boston  Med.  and  Surg.  Jour.,  1864,  lxx,  73. 
Tilhnanns,  H:  Ueber  angeborenen  Prolaps  von  Magenschleimhaut  durch  den  Nabelring  (Ectopia 

ventriculi),  und  iiber  sonstige  Geschwulste  und  Fisteln  des  Nabels.     Deutsche  Zeitschr.  f. 

Chir.,  1882-83,  xviii,  161. 
Tisserand,  G. :  A  propos  de  deux  cas  de  cancer  secondaire  de  I'ombilic.     La  Loire  med.,  St.  Etienne, 

1906,  xxv,  131-136. 
Valette,  A.:  Contribution  a  1' etude  du  cancer  secondaire  de  I'ombilic.     These  de  Paris,  1898,  No. 

550. 
Villar,  F. :  Tumeurs  de  I'ombilic.     These  de  Paris,  1886. 
Wulckow:   Beitrag  zur  Casuistik  der  Nabelneubildungen.     Berlin,  klin.  Wochenschr.,  1875,  xii, 

533. 


CARCINOMA  OF  THE  UMBIXICUS  SECONDARY  TO  CANCER  OF  THE  GALL-BLADDER. 

Inasmuch  as  primary  carcinoma  of  the  gall-bladder  is  relatively  rare,  we  should 
not  expect  to  find  many  growths  of  the  umbilicus  secondary  to  it.  Ledderhose, 
in  1890,  reported  a  case  that  he  had  observed  in  Kussmaul's  clinic.  A  woman, 
fifty-six  years  old,  was  brought  to  the  hospital  on  account  of  jaundice.  It  was 
impossible  to  detect  any  growth  in  the  liver  either  by  palpation  or  percussion.  At 
the  umbilicus,  however,  was  a  bean-sized,  hard  tumor  which  suggested  the  diag- 
nosis of  carcinoma  of  the  liver  or  of  the  gall-bladder.  Subsequently  it  became  pos- 
sible  to  detect  large  and  irregular  masses  with  nodular  margins  in  the  liver.  At 
autopsy  a  primary  carcinoma  of  the  gall-bladder  was  found  which  had  given  rise 
to  the  umbilical  growth. 

In  1901  Besson  gave  a  splendid  resume  of  the  literature  on  secondary  carcinoma 
of  the  umbilicus,  and  cited  a  case  of  carcinoma  of  the  gall-bladder  with  a  secondary 
growth  at  the  umbilicus.     The  umbilical  growth  was  the  size  of  a  small  hazelnut. 

The  histologic  pictures  from  this  case  are  given  in  Figs.  225,  226,  and  227  of 
(  oinil  and  Ranvier's  Manuel  d'histologie  pathologique,  published  in  the  same  year. 


CARCINOMA    OF    THE    UMBILICUS.  423 

Tisserand,  in  1906,  reported  a  case  of  this  character.  A  woman,  fifty-four  years 
old,  the  mother  of  four  children,  had  had  pain  for  five  months  in  the  umbilical 
region,  but  her  general  health  had  been  good.  On  abdominal  examination  the 
cicatrix  of  the  umbilicus  seemed  to  be  simply  inflamed.  It  was  very  red,  slightly 
painful,  and  indurated.  An  exploratory  operation  was  performed.  The  patient 
died  suddenly  on  the  tenth  day.  There  was  a  carcinoma  of  the  gall-bladder  with 
biliary  stones.  The  glands  along  the  suspensory  ligament  of  the  umbilicus  showed 
a  bead-like  involvement.  No  trace  of  cancer  could  be  found  in  any  other  organ. 
In  this  case  there  was  a  definite  carcinomatous  extension  along  the  lymphatics. 

Schlesinger,  in  1911,  reported  a  case  of  primary  carcinoma  of  the  gall-bladder 
with  a  secondary  nodule  at  the  umbilicus. 

In  this  connection  the  following  case  of  biliary  fistula  reported  by  Gross  may  be 
of  interest: 

Biliary  Fistula  at  the  Umbilicus.*  —  A  man,  aged  forty- 
four,  two  months  before  had  noticed  a  small  lump  at  the  umbilicus;  it  was  not 
painful,  but  caused  a  continuous  pricking  sensation.  The  lesion  had  progressively 
enlarged,  and  on  admission  the  umbilical  growth  was  the  size  of  a  large  red  button 
and  the  man  had  a  continuous  dull  pain.  For  a  month  it  had  been  severe  enough 
to  prevent  him  from  sleeping.  The  patient  had  become  emaciated,  but  had  had 
no  intestinal  disturbances. 

On  admission  he  was  thin,  and  grayish  in  color.  On  January  29th  a  tumor 
covered  by  intact  red  skin  was  removed.  It  was  adherent  to  the  peritoneum. 
Microscopic  examination  showed  it  to  be  a  cancer.  The  patient  developed  pneu- 
monia, but  recovered  from  it.  On  February  18th,  an  irritating  biliary  discharge 
was  noted,  but  no  inflammatory  reaction.  He  left  the  hospital  on  March  11th 
well  of  his  pneumonia,  but  with  a  biliary  fistula. 

Gross  thinks  that  the  gall-bladder  had  become  adherent  to  the  umbilicus,  and 
after  operation  a  small  abscess  had  developed  and  perforation  of  the  gall-bladder 
had  taken  place. 

[It  is  just  possible  that  a  primary  carcinoma  of  the  gall-bladder  existed  in  this 
case.— T.  S.  C] 

While  reviewing  the  literature  on  diseases  of  the  umbilicus  I  was  asked  to  see 
the  following  case,  and  profiting  by  the  knowledge  gleaned  from  the  literature,  at 
once  ventured  a  provisional  diagnosis  of  either  carcinoma  of  the  stomach  or  of 
the  gall-bladder  with  gall-stones  and  a  secondary  malignant  growth  at  the  um- 
bilicus. 

Adenocarcinoma  'of  the  Umbilicus  Secondary  to  Car- 
cinoma of  the  G  a  1 1  -  b  1  a  d  d  e  r  .  f  —  Mrs.  B.,  aged  fifty-eight,  was  seen 
in  consultation  with  Dr.  George  L.  Wilkins  and  admitted  to  the  Church  Home  and 
Infirmary  April  24,  1910. 

The  patient  showed  a  slight  bulging  at  the  umbilicus  on  standing.  This  was 
painful  when  the  clothes  rubbed  against  it.  It  had  been  noticed  first  in  December, 
1909,  that  is,  about  four  months  before  examination.  For  some  months  the  patient 
had  suffered  at  intervals  with  pain  in  the  region  of  the  gall-bladder  and  had  been 
jaundiced.  The  pain  had  radiated  to  the  back  and  to  the  right  shoulder.  At  the 
time  of  examination  there  was  some  tenderness  in  the  gall-bladder  region.     She 

*  Gross,  G.:  Neoplasme  de  l'ombilic.     Revue  med.  de  Test.,  Nancy,  1898,  xxx,  559. 
f  I  reported  this  case  in  Jour.  Amer.  Med.  Assoc,  1911,  lvi,  391. 


424 


THE    UMBILICUS    AND    ITS    DISEASES. 


A. 


m 


had  suffered  from  the  presence  of  gas  and  from  constipation.     No  clay-colored 
stools  had  been  noted.     The  heart,  lungs,  and  kidneys  were  normal. 

From  the  history  and  general  condition  a  provisional  diagnosis  was  made  of 

either  cancer  of  the  stomach 
or  of  the  gall-bladder,  asso- 
ciated with  a  secondary  no- 
dule at  the  umbilicus.  On  ex- 
amination of  the  umbilicus 
there  was  just  a  slight  rolling- 
out,  but  nothing  to  suggest  a 
nodule  until  one  picked  the 
umbilicus  up  between  the  fin- 
gers, when  marked  sensitive- 
ness became  apparent  (Fig. 
184). 

Operation.  —  April  25, 
1910.  On  making  a  right  rec- 
tus incision  I  at  once  encoun- 
tered little  nodules  in  the 
lesser  omentum.  The  gall- 
bladder contained  numerous 
stones  and  also  a  new-growth. 
The  latter  was  firm  and  had 
extended  to  the  lymph-glands 
around  the  portal  vein.  One 
of  these  was  over  3  cm.  in  di- 
ameter. We  were  dealing 
with  a  carcinoma  of  the  gall- 
bladder, together  with  metas- 
tases in  the  lesser  omentum 
and  the  umbilicus.  On  ac- 
count of  the  marked  involve- 
ment of  the  lymph-glands 
complete  removal  of  the  prim- 
ary growth  was  impossible. 
As  the  patient  had  had  a  great 
deal  of  pain  in  the  umbilicus, 
this  was  removed.  The  inner 
or  peritoneal  surface  of  the 
umbilicus  was  free  from  ad- 
hesions. The  patient  made  a 
good  temporary  recovery  and 
was  discharged  May  9,  1910. 
She  subsequently  developed 
large  secondary  nodules  in  the  abdominal  cavity,  and  died  on  September  16,  1910. 
Pathologic  Examination  (Path.  No.  14968). — The  specimen  consists  of  the 
umbilicus  and  surrounding  skin.  It  is  7  cm.  in  length,  5  cm.  in  breadth.  The 
umbilicus  is  slightly  prominent.     It  is  commencing  to  unfold  a  little,  as  seen  in  Fig. 


B. 


^Y 


Fig.  184. — Appearance  op  the  Carcinomatous  Umbilicus  After 
Removal.  (Natural  size.) 
Path.  No.  14968.  A.,  The  parts  are  slightly  distorted  from  the  ac- 
tion of  the  hardening  fluid  and  the  umbilicus  comes  out  more  promi- 
nently than  it  really  did  in  the  patient.  There  is,  however,  a  slight  un- 
folding of  the  umbilicus,  and  one  part  seems  somewhat  raised.  The 
umbilicus  itself,  however,  was  perfectly  intact.  B.,  A  transverse  sec- 
tion through  the  umbilicus.  The  half  to  the  left  is  more  prominent 
and  represents  the  elevation  noted  in  the  umbilical  depression.  The 
surface,  however,  is  intact.  There  is  an  increase  in  the  amount  of 
connective  tissue,  but  no  evidence  of  any  definite  nodule.  Histologic 
examination  showed  that  this  area  was  everywhere  infiltrated  with 
carcinomatous  glands. 


CARCINOMA    OF    THE    UMBILICUS.  425 

184.  It  was  not  quite  so  prominent,  however,  in  the  fresh  state.  The  nodule 
could  be  readily  felt  on  lifting  the  umbilicus  up  with  the  fingers.  It  appeared  to  be 
about  1  cm.  or  more  in  diameter.  In  the  hardened  specimen  the  tissue  was  con- 
tracted, bringing  the  tumor  out  more  prominently.  The  skin  was  everywhere  in- 
tact. The  peritoneal  surface  was  slightly  puckered,  but  was  free  from  adhesions. 
On  section  of  the  umbilicus  the  tissue  looked  fibrous  and  in  its  middle  portion 
was  what  appeared  to  be  a  little  area  of  hemorrhage  about  2  mm.  in  diameter. 
At  first  sight  one  would  not  for  a  moment  suspect  the  presence  of  carcinoma. 

Histologic  Examination.  —  The  squamous  epithelium  is  intact, 
and  immediately  beneath  it  in  a  few  places  are  some  sweat-glands.  Approaching 
the  peritoneum  colonies  of  glands  are  found  closely  packed  together  with  very  little 
connective  tissue  between  them.  The  gland  epithelium  is  for  the  most  part  one 
layer  in  thickness.  In  some  places  it  is  cuboid,  at  other  points  cylindric,  and  there 
are  very  minute  glands.  The  nuclei  of  the  epithelial  cells  stain  uniformly,  but  vary 
considerably  in  size.  In  some  places  the  epithelial  cells  seem  to  have  a  tendency  to 
be  arranged  in  single  rows.  The  growth  is  without  doubt  a  carcinoma.  The  small 
metastatic  nodules  found  in  the  lesser  omentum  in  the  neighborhood  of  the  gall- 
bladder present  a  precisely  similar  appearance.  We  are  undoubtedly  dealing  with 
a  primary  carcinoma  of  the  gall-bladder,  involving  the  lymphatics  around  the  portal 
vein.  There  have  been  metastases  in  the  lesser  omentum  and  also  involvement 
of  the  umbilicus. 

Treatment. — When  the  diagnosis  is  perfectly  clear,  operation  is  not  indicated, 
as  it  is  impossible  completely  to  eradicate  the  disease.  In  my  case  the  operation 
was  undertaken  solely  on  account  of  the  severe  pain  caused  by  the  umbilical  nodule. 


LITERATURE  CONSULTED  ON  CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO 

CANCER  OF  THE  GALL-BLADDER. 
Besson,  E.:  Cancer  de  l'ombilic.     These  de  Paris,  1901,  Xo.  263. 
Cornil  et  Ranvier:  Manuel  d'histologie  pathologique,  3.  ed.,  Paris,  1910,  i,  493. 
Gross,  G. :  Xeoplasme  de  1'ombilic.     Revue  med.  de  Test.,  Nancy,  1898,  xxx,  559. 
Ledderhose,  G. :  Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Schlesinger:    Die  Bedeutung  der  Nabelmetastasen  fur  die  Diagnose  abdomineller  Xeoplasmen. 

Wien.  med.  Wochenschr.,  1911,  Xr.  8,  519. 
Tisserand,  G. :  A  propos  de  deux  cas  de  cancer  secondaire  de  1'ombihc.     La  Lone  med.,  St.  Etienne, 

1906,  xxv,  131-136. 


CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO  CANCER  OF  THE  INTESTINE. 

I  have  found  five  cases  of  this  character  in  the  literature,  those  of  Lage,  Chu- 
quet,  Villar,  Pernice,  and  Barker.  It  is  quite  probably  that  Plagge's  case  also 
belongs  to  this  group,  although  the  tumor  was  described  as  a  myxosarcoma.  In 
Chuquet's  case  the  carcinoma  was  situated  in  the  rectum. 

On  reading  the  histories  of  these  cases  it  will  be  seen  that  in  the  majority  of 
the  cases,  in  addition  to  the  primary  growth,  there  were  wide-spread  abdominal 
metastases  facilitating  extension  of  the  carcinomatous  process  to  the  umbilicus. 

Histologically,  the  umbilical  growths  conform  exactly  to  the  type  of  the  original 
intestinal  tumor. 


420  THE    UMBILICUS    AND    ITS    DISEASES. 

Cases  of  Carcinoma  of  the  Umbilicus  Secondary  to  Cancer  of  the  Intestine. 

Carcinoma  of  the  Large  Bowel  "With  Metastases  at 
the  Umbilicus.*  —  The  patient  died  of  carcinoma  involving  nearly  all  of 
the  large  bowel.  There  were  metastases  in  the  mesenteric  glands.  At  the  umbili- 
cus was  a  brownish  red.  mottled  growth.  The  umbilicus  felt  like  a  broad,  hard, 
flat  surface.  The  growth  was  probably  a  carcinoma  secondary  to  that  of  the  large 
bowel. 

Carcinoma  of  the  Rectum  With  Seco  n  d  a  r  y  Carci- 
noma at  the  Umbilicus,  f  —  This  case  had  been  reported  by  Lebert 
(Bull.  Soc.  anat.  de  Paris).  A  woman,  fifty-four  years  of  age,  six  weeks  before 
coming  under  observation  had-  commenced  to  have  violent  colic  and  pain  at  the 
umbilicus  with  digestive  disturbances.  On  admission  she  looked  cachectic  and  the 
abdomen  was  much  distended.  Beneath  the  umbilicus  was  felt  a  hard,  cartilagin- 
ous plaque  which  at  its  prominent  part  raised  the  skin  nearly  3  cm. 

At  autopsy  small  carcinomatous  masses  were  found  scattered  over  the  peri- 
toneum and  there  was  a  scirrhous  carcinoma  of  the  rectum.  The  umbilical  growth 
had  developed  in  the  linea  alba. 

[Although  the  growth  was  probably  secondary  to  that  in  the  rectum,  one  cannot 
feel  absolutely  sure. — T.  S.  C] 

Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma 
of  the  Transverse  Colon.- —  Villar %  describes  a  case  occurring  in  the 
sen-ice  of  Damaschino.  The  patient,  fifty-three  years  of  age,  had  a  cancer  of  the 
transverse  colon  involving  the  omentum,  cancerous  nodules  in  the  peritoneum, 
ulceration  and  cancer  of  the  umbilicus,  and  seconda^  nodules  in  the  liver. 

During  the  progress  of  the  disease  a  hard  mass  developed  in  the  umbilical 
region,  and  in  two  months  the  umbilical  depression  was  effaced  by  a  violet  mass 
which  reached  the  dimensions  of  a  two-franc  piece.  This  was  covered  with  a  thick 
crust.  When  this  was  removed,  the  new-growth  was  found  to  be  nodular,  irregular, 
and  reddish.  On  palpation  one  could  feel  in  the  umbilical  region,  over  an  area 
10  cm.  in  diameter,  a  hard,  slightly  movable,  mass.  At  autopsy  it  was  found  that 
the  tumors  of  the  omentum  and  of  the  peritoneum,  as  well  as  the  umbilical  mass, 
were  of  exactly  the  same  structure  as  the  intestinal  growth. 

Cancer  of  the  Transverse  Colon  with  Secondary  Car- 
cinoma of  the  Umbilicus.§  —  Case  1. —  "A  man,  aged  thirty- 
seven,  admitted  to  the  University  College  Hospital  February  3,  1910.  In  March, 
1909.  he  noticed  occasional  pains  around  the  navel  irrespective  of  food.  These 
lasted  three  or  four  months.  In  the  July  following  he  entered  a  country  hospital, 
having  noticed  for  about  a  fortnight  a  swelling  in  the  abdominal  wall  at  the  umbili- 
cus.  This  was  opened  with  the  knife  on  July  24th  and  was  said  to  have  given  exit 
to  pus  and  to  have  healed  again  in  a  week.  In  the  September  following  the  swell- 
ing increased  ag:ain  and  burst,  and  has  been  discharging  ever  since.  On  admission 
on  February  3d  he  was  well  nourished.  Below  and  to  the  left  of  the  navel  was  a 
discolored  and  irregular  prominence  about  2}/>  inches  in  diameter,  with  a  wound 

*  Lage:  Krebshafte  Entartung  eines  grossen  Theils  des  Dickdarms.  Schmidt's  Jahrbuch, 
1847,  Iv,  295. 

fChuquet:   Du  carcinome  generalise  du  peril oine.     These  de  Paris,  1879,  No.  548,  obs.  18. 
i  Villar,  F. :  Tumeurs  de  l'ombilic.     These  de  Paris,  1886,  obs.  78,  112. 
j  Barker,  A.  E.:  TheLancet,  London,  July  19,  1913. 


CARCINOMA    OF    THE    UMBILICUS.  427 

discharging  through  the  old  scar.  On  palpation  the  induration  was  much  larger 
than  it  looked.  It  extended  downward  for  several  inches  in  the  left  rectus  muscle 
and  was  everywhere  very  hard.  Except  to  the  skin  over  the  most  prominent  part, 
it  showed  no  attachment  anteriorly,  but  was  incorporated  with  the  rectus.  The 
discharging  sinus  led  downward  and  outward  about  V/2.  inches.  To  be  quite  sure 
of  its  nature,  which  was  believed  to  be  cancerous,  I  made  an  incision  into  the  swell- 
ing, and,  finding  it  unmistakably  so,  prepared  for  removal.  This  was  done  on  Feb- 
ruary 20th,  between  two  long  elliptic  incisions  from  above  downward,  opening  the 
abdomen  and  including  most  of  the  left  rectus  muscle.  The  tumor  was  then  seen 
to  be  obviously  a  growth  of  the  transverse  colon  fungating  through  the  umbilicus. 
I  then  clamped  the  colon  on  each  side  and  removed  it  with  about  IY2  inches  on  both 
sides  of  the  growth — about  seven  or  eight  inches  in  all.  The  ends  of  the  divided 
bowel  were  brought  together  in  the  usual  way,  and  the  wound  was  only  partially 
closed,  as  there  was  little  or  no  muscle  to  fill  it.  Some  suppuration  followed,  as  I 
expected,  from  the  foul  state  of  the  breaking-down  growth,  and  a  fecal  fistula  formed 
for  a  little  while,  but  soon  closed  and  the  wound  granulated  up.  On  May  6th  I 
removed  a  nodule  of  growth,  cutting  the  skin  and  inserting  a  delicate  wire  netting. 
Since  then  all  has  gone  well,  and  I  have  recently  seen  the  man — more  than  three 
years  after  the  operation — quite  free  from  any  sign  of  recurrence.  He  plays  golf 
and  performs  on  a  wind  instrument;  he  has  no  hernia. 

"The  growth  was  a  typical  columnar  carcinoma,  and  corresponded  to  an  ulcer 
on  the  mucous  surface  of  the  free  side  of  the  transverse  colon,  as  large  as  a 
crown  piece,  with  everted  edges.  There  were  no  tangible  glands  in  the  mesentery 
or  any  other  signs  of  generalization." 

Secondary  Carcinoma  of  the  Umbilicus.*  —  Case  129, 
reported  from  the  Frauenklinik  of  Breslau.  A  woman,  fifty-two  years  of  age,  com- 
plained of  a  sticking,  burning  pain,  which  was  more  marked  on  pressure.  The  ab- 
domen was  much  distended.  In  the  vicinity  of  the  stomach  and  also  in  the  region 
of  the  umbilicus  nodules  could  be  made  out.  The  patient  looked  weak  and  cachec- 
tic. In  the  umbilical  region  there  was  marked  resistance.  This  extended  three 
fmgerbreadths  to  the  right  and  over  a  handbreadth  and  a  half  to  the  left.  On 
account  of  the  ascites,  nothing  more  could  be  made  out.  There  was  a  small  umbili- 
cal tumor.  At  an  exploratory  operation  carcinomatous  nodules  were  found  on  the 
intestine,  and  the  omentum  was  everywhere  covered  with  small  carcinomatous 
nodules. 

A  Case  of  Myxosarcoma  of  the  Umbilicus. [?]f  —  In  child- 
hood the  man  had  difficulty  in  digestion,  and  later  vomiting  and  diarrhea.  In  the 
summer  of  1887  he  had  pain  in  the  stomach  for  the  first  time  and  noticed  a  small 
tumor  at  the  umbilicus.  By  November  of  the  same  year  the  tumor  had  reached 
the  size  of  a  hazel-nut,  and  four  weeks  later  a  nodule  the  size  of  a  pea  below  and  to 
the  left,  close  to  the  linea  alba,  could  be  felt.  The  patient  became  emaciated  and 
died  on  March  14,  1888.  At  autopsy  the  umbilicus  showed  a  thickening,  the  size 
of  a  five-franc  piece,  raised  2  cm.  above  the  abdominal  level.  Above  and  below,  the 
thickening  could  be  followed  5  cm.  in  each  direction.  The  skin  was  movable  over 
the  area  of  thickening.  When  the  abdomen  was  opened,  a  nodule  2  mm.  in  diam- 
eter was  found  in  the  umbilical  region.     In  the  ligament  passing  from  the  umbilicus 

*  Pernice,  L.:   Die  Nabelgeschwiilste,  Halle,  1892. 

t  Plagge,  H.:  Em  Fall  von  Myxosarcoma  des  Xabel.     Inaug.  Diss.,  Freiburg  i.  B.,  1889. 


428  THE    UMBILICUS    AND    ITS    DISEASES. 

were  small  nodules.  The  omentum,  diaphragm,  and  intestine  were  implicated. 
The  stomach  was  normal.  Microscopically,  a  diagnosis  of  myxosarcoma  was  made. 
[The  clinical  picture  in  no  way  indicated  a  primary  growth.  The  condition 
resembles  in  some  degree  a  case  of  a  colloid  carcinoma  of  the  intestine  with 
secondary  growths  at  the  umbilicus. — T.  S.  C.l 


LITERATURE  CONSULTED  ON  CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO 

CANCER  OF  THE  INTESTINE. 
Barker,  A.  E.:  Three  Cases  of  Solid  Tumors  of  the  Umbilicus  in  Adults.     The  Lancet,  London, 

July  19,  1913. 
Chuquet,  A. :  Du  carcinome  generalise  du  peritoine.     These  de  Paris,  1879,  No.  548. 
Lage:  Krebshafte  Entartung  eines  grossen  Theils  des  Dickdarms.     Schmidt's  Jahrbuch,  1847,  lv, 

295. 
Pernice,  L. :  Die  Nabelgeschwulste,  Halle,  1892. 

Plagge,  H. :  Ein  Fall  von  Myxosarcom  des  Nabel.     Inaug.  Diss.,  Freiburg  i.  B.,  1889. 
Villar,  F. :  Tumeurs  de  l'ombilic.     These  de  Paris,  1886,  obs.  78. 


CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO  OVARIAN  CARCINOMA. 

I  have  found  several  cases  of  this  character  in  the  literature,  and  two  have  been 
observed  in  the  Gynecological  Department  of  the  Johns  Hopkins  Hospital.  A  very 
careful  review  of  the  subject  was  given  by  Le  Coniac  in  his  thesis  published  in  1898. 

The  youngest  of  the  patients  here  recorded  was  thirty-two  years  of  age;  the 
oldest,  sixty-eight.  Five  of  the  nine  patients  were  between  fifty  and  sixty  years  of 
age. 

Most  of  the  umbilical  growths  were  small,  and  some  of  them  were  very  hard. 
In  Gueneau  de  Mussy's  case  the  growth  was  pedunculated.  A  small  umbilical  her- 
nia had  existed,  and  a  month  before  the  patient  came  under  observation  it  had 
become  irreducible.  It  then  became  very  hard,  and  was  evidently  infiltrated  with 
cancer.  In  Burkhart's  case,  in  addition  to  the  umbilical  nodule,  there  was  also  one 
attached  to  a  rib.  The  umbilical  nodule  in  one  of  Demons  and  Verdelet's  cases 
was  ulcerated.  In  one  of  our  cases  (Gyn.  No.  6150)  there  was  a  round,  ulcerated 
area  with  sharply  cut  edges  and  a  granular  base.  As  seen  from  Fig.  185  (p.  432) 
the  floor  of  this  ulcer  consisted  of  carcinomatous  tissue.  In  Aslanian's  case  the 
carcinoma  had  extended  to  the  inguinal  glands. 

It  is  hardly  necessary  to  analyze  the  histories  of  these  cases,  as  the  findings  are 
common  to  those  ordinarily  noted  where  carcinoma  of  the  ovaries,  together  with 
wide-spread  peritoneal  carcinosis,  is  present.  It  will  be  noted  that  in  all  but  one  of 
the  cases  there  was  a  wide-spread  peritoneal  carcinosis,  and  consequently  secondary 
involvement  of  the  umbilicus  was  relatively  easy. 

The  histologic  picture  of  these  umbilical  nodules  naturally  corresponds  to  that 
present  in  primary  ovarian  tumors.  In  Fig.  185,  which  Mr.  Hart  kindly  photo- 
graphed for  me,  we  see  the  edge  of  the  carcinomatous  nodule  in  case  Gyn.  No. 
6150.  The  growth  can  be  traced  through  the  abdominal  wall  as  far  as  the  epi- 
thelial covering  of  the  umbilicus.  Over  the  area  of  ulceration  the  skin  covering  had 
disappeared  entirely  and  the  carcinomatous  tissue  formed  the  floor  of  the  ulcer. 
Any  operative  treatment  in  these  cases  is  of  little  or  no  value. 


CARCINOMA    OF    THE    UMBILICUS.  429 

Cases  of  Carcinoma  of  the  Umbilicus  Secondary  to  Ovarian  Carcinoma. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma 
of  the  Ovaries.  —  Aslanian*  covers  the  literature  on  peritoneal  carcinosis 
very  thoroughly.  He  cites  the  following  case:  A  woman,  aged  thirty-five,  had 
cancer  of  the  ovaries  with  metastases  to  the  abdominal  peritoneum.  Eleven 
months  before  she  had  given  birth  to  a  child.  Fifteen  days  later  she  had  com- 
menced to  suffer  with  abdominal  pain  and  developed  an  induration  at  the  umbilicus. 
The  umbilical  growth  had  finally  ulcerated,  and  it  was  for  this  that  the  patient  en- 
tered the  hospital.  During  surgical  intervention  metastatic  nodules  were  noted 
in  the  parietal  peritoneum.  The  patient  recovered  from  the  operation,  but  did  not 
improve.  The  appetite  diminished  more  and  more,  and  she  became  thin.  She 
returned  to  the  hospital  on  account  of  the  abdominal  pain  and  another  growth  in 
the  umbilical  region.  At  the  site  of  the  umbilicus  the  scar  contained  a  soft  tumor 
the  size  of  a  walnut.  In  both  inguinal  regions  the  glands  were  enlarged  and 
formed  two  elongate  tumors  parallel  with  the  inguinal  folds.  One  could  detect 
beneath  the  integument  of  the  abdominal  wall  some  small  nodules  the  size  of  len- 
tils or  peas,  and  over  these  the  skin  was  adherent.  To  the  left  of  the  tumor  was.  a 
hard  cord,  3  to  4  cm.  long,  which  terminated  in  the  enlarged  glands.  Deeper  down, 
nodules  could  be  made  out  in  the  hypogastrium.  At  the  level  of  the  umbilicus  on 
the  right  was  a  deep-seated  induration.  Palpation  was  not  painful,  and  there  was 
an  accumulation  of  ascitic  fluid. 

All  the  time  the  patient  was  in  the  hospital  she  continued  to  complain  of  pain. 
The  emaciation  increased,  and  toward  the  end  of  her  illness  there  was  edema  of  the 
feet. 

At  autopsy  the  peritoneal  cavity  was  found  to  contain  300  c.c.  of  reddish  fluid. 
In  the  pelvis  the  normal  relations  were  markedly  altered.  Both  ovaries  had  been 
converted  into  hard  tumors  the  size  of  apples.  They  were  nodular  and  had  uniform 
surfaces.  The  left  ovary  presented  a  small  cyst.  On  section,  the  tumors  were 
found  to  have  a  uniform,  hard,  grayish  surface,  with  yellowish  areas  scattered  here 
and  there  through  them.  The  Fallopian  tubes  showed  hypertrophy.  Their 
extremities  -were  free,  but  the  mucosa  of  the  fimbriae  contained  cancerous  nodules 
which  were  yellowish  in  color,  very  hard,  and  simulated  eruptions  of  tubercles. 
The  entire  peritoneum  was  involved  in  the  cancer.  The  neck  of  the  cervix  was  hard 
and  infiltrated  in  its  entire  thickness  with  numerous  cancerous  nodules,  some  as 
large  as  a  pea.  In  addition  to  the  wide-spread  peritoneal  involvement,  the  omen- 
tum was  contracted  into  numerous  folds  and  contained  cancerous  nodules.  It 
was  adherent  to  the  abdominal  wall  at  the  umbilicus.  At  this  point  the  cancerous 
nodules  were  very  abundant.  The  small  intestines  did  not  show  any  secondary 
nodules,  but  there  were  some  in  the  mesentery.  The  liver  was  voluminous  and 
nodular,  and  occupied  all  the  epigastrium.  Glisson's  capsule  did  not  contain  any 
nodules,  but  in  the  hepatic  tissue  there  were  15  secondary  growths  varying  from 
the  volume  of  a  pomegranate  to  that  of  a  peach  in  size.  On  the  inferior  surface  of 
the  diaphragm  on  the  right  side  were  cancerous  plaques.  On  the  anterior  ab- 
dominal wall  were  whitish  cords.  These  were  cancerous  lymphatics,  following 
the  direction  of  the  umbilical  arteries,  and  terminating  at  the  umbilical  tumor 

*  Aslanian,  G.:    Contribution  a  l'etude  de  la  peritonite  cancereuse.     These  de  Paris,  1895, 
No.  150,  obs.  70. 


430  THE    UMBILICUS    AND    ITS    DISEASES. 

where  the  omentum  was  adherent  to  the  abdominal  wall.  The  nodules  at  this 
point  varied  from  the  size  of  a  pin-head  to  that  of  a  pea.  Cancerous  nodules  were 
present  in  the  thorax. 

On  histologic  examination,  the  ovary,  uterus,  intestine,  muscle,  and  peritoneum 
of  the  umbilical  tumor  all  showed  an  alveolar  carcinoma.  Aslanian  says  that  preg- 
nancy played  a  large  role  in  the  provocation  of  the  generalization  of  the  cancer, 
not  only  on  the  serous  surfaces,  but  also  in  the  generative  organs  and  in  the  anterior 
abdominal  wall.     His  article  is  a  very  thorough  one. 

Carcinoma  of  the  Umbilicus  Secondary  to  Ovarian 
Carcinoma.  —  Burkhart*  reports  Kiister'sf  case  of  a  woman,  fifty-seven 
years  of  age,  who  had  had  several  labors.  Two  years  before  she  had  complained  of 
a  dull  feeling  in  the  lower  abdomen,  and  six  months  before  a  small  nodule  had  been 
detected  at  the  umbilicus;  two  months  before  coming  under  observation  nodules 
had  been  noted  on  the  ribs  near  the  sternum.  At  the  time  of  the  patient's  death 
the  tumor  at  the  umbilicus  was  the  size  of  a  nut.  The  overlying  skin  was  movable. 
The  malignant  growth  had  involved  the  uterus  and  ovaries.  It  had  originally  been 
an  ovarian  cyst  and  had  become  carcinomatous. 

Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma 
of  the  Ovary.  J  - —  Case  1. — A  woman,  forty-five  years  of  age,  for  a  month 
had  had  an  abdominal  enlargement.  She  was  thin,  and  the  abdomen  contained  an 
accumulation  of  fluid.  At  the  umbilicus  was  a  small  tumor.  Deep  palpation 
revealed  a  large  tumor  attached  to  the  uterus.  At  operation  the  abdomen  was 
found  to  contain  pelvic  tumors.  There  were  papillomata  involving  the  intestine 
and  the  omentum,  and  converting  the  ovaries  and  uterus  into  one  mass.  The  fluid 
was  removed,  and  the  umbilical  tumor  taken  away.  The  histologic  picture  noted 
in  the  umbilical  tumor  was  identical  with  that  frequently  found  in  the  ovary. 

Cancer  of  the  Ovaries  with  a  Secondary  Growth  at 
the  Umbilicus.§  —  Case  2. — A  woman,  fifty-three  years  of  age,  for  nine 
months  had  had  abdominal  pain.  Shortly  after  falling  on  her  abdomen  she  had 
noticed  a  small,  non-painful  enlargement.  The  abdomen  increased  in  size  and  the 
patient  became  emaciated.  On  examination  abundant  free  fluid  was  found.  At 
the  umbilicus  was  a  small  tumor  which  was  not  ulcerated  and  lay  beneath  the  skin. 
Hard,  fixed  masses  could  be  felt  in  the  lower  abdomen.  Vaginal  examination 
revealed  a  nodular,  irregular  tumor.  The  condition  was  diagnosed  as  carcinoma  of 
the  ovaries  with  secondary  carcinoma  of  the  umbilicus.  At  operation  12  liters  of 
ascitic  fluid  were  removed.  Tumors  were  found  filling  Douglas'  cul-de-sac.  At- 
tached to  the  parietal  peritoneum  were  several  secondary  nodules,  and  the  omen- 
tum formed  a  tumor  mass.  The  umbilical  growth  was  removed  and  the  abdomen 
closed. 

Probable  Carcinoma  of  the  Ovary  with  a  Secondary 
Growth  at  the  Umbilicus.  ||  —  A  woman,  sixty-eight  years  of  age,  a 
year  before  admission  had  had  abundant  uterine  hemorrhages  and  since  then  had 
been  ill.     The  abdomen  was  slightly  distended.     Her  appetite  had  gone,  she  was 

*  Burkhart,  ().:   Uebcr  don  Xabelkrebs.     Inaug.  Diss.,  Berlin,  1889. 
f  Krister:  Beitrage  z.  Geb.  u.  Gyn.,  1875,  iv,  6. 

%  Demons  et  Verdelet:  Cancer  secondaire  de  l'ombilic.  Congres  pcriodique  de  gyn., 
d'obstet.  et  de  paed.,  1898,  ii,  344. 

§  Demons  et  Verdelet:  Op.  cit.  ||  Demons  et  Verdelet:  Op.  cit. 


CARCINOMA    OF    THE    UMBILICUS.  431 

con.stipai.ecl,  and  had  been  gradually  wasting  away.  She  had  pain  in  the  abdomen. 
Two  months  previously  she  had  first  noticed  at  the  umbilicus  a  hard,  irregular 
tumor,  which  soon  ulcerated.  Eight  days  before  admission  jaundice  had  become 
pronounced.  On  examination  the  abdomen  was  found  distended,  tympanitic,  and 
at  the  umbilicus  was  a  small,  indurated  tumor  with  diffuse  margins.  It  was  ulcer- 
ated. A  diagnosis  of  cancer  was  made.  In  Douglas'  pouch  was  a  tumor.  The 
outlines  were  not  clear.  The  patient  was  too  weak  for  operation.  The  condition 
was  diagnosed  as  cancer  of  the  ovaries  with  secondary  growths  at  the  umbilicus. 
[Of  course,  there  is  a  chance  for  error  in  this  case,  as  no  operation  was  performed. — 
T.  S.  C] 

Probable  Carcinoma  of  the  Umbilicus  Secondary  to 
Carcinoma  of  the  Ovaries.*  —  A  woman,  fifty-nine  years  of  age,  for 
three  months  had  been  supposed  to  have  influenza.  Two  months  before  coming 
under  observation  she  had  become  yellow  and  had  had  pain  in  the  abdomen.  On 
admission  she  was  jaundiced,  had  lost  weight,  vomited  bile,  and  gave  a  history  of 
vomiting  blood  on  one  occasion.  At  the  umbilicus  was  a  knob-like  hardness  drawn 
inward,  as  if  pulled  by  something  from  within.  At  autopsy  carcinoma  of  both 
ovaries  was  found.  There  were  small  nodules  in  the  peritoneum  and  pleurse. 
The  gall-bladder  was  small  and  filled  with  stones.  The  common  duct  was  com- 
pressed by  cancerous  nodules.  The  growth  at  the  umbilicus  was  apparently  sec- 
ondary to  that  in  the  ovaries. 

Carcinoma  of  the  Umbilicus  Secondary  to  Cancer  in 
the  Pelvis.- —  Gueneau  de  Mussy's  t  patient,  a  woman  fifty-nine  years  old, 
was  suffering  from  an  obscure  abdominal  lesion.  At  the  umbilicus  was  a  small, 
hard  disc,  the  size  of  a  large  almond,  attached  by  a  pedicle  in  the  umbilical  ring. 
The  patient  said  she  had  had  a  small  hernia,  easily  reducible,  but  for  the  past 
month  it  had  been  hard  and  remained  outside. 

At  autopsy,  several  months  later,  an  abdominal  carcinoma  was  found.  The 
pelvis  contained  a  mass  the  size  of  a  new-born  child's  head,  and  other  foci  existed. 

Probable  Adenocarcinoma  of  the  Umbilicus  Second- 
ary to  Carcinoma  of  the  Ovary.  —  Gyn.  No.  2004;  Path.  Xo.  8. 
Mrs.  C.  W.,  aged  thirty-two.  Admitted  to  the  Johns  Hopkins  Hospital  May  25, 
1893.  Operation  by  Dr.  Kelly.  The  abdomen  contained  about  8  ounces  of 
ascitic  fluid;  the  peritoneum  was  dark  in  color.  The  right  ovary  was  the  size  of 
an  orange,  and  was  surrounded  by  a  capsule  34  mch  in  thickness.  This  was  easily 
torn.  Several  small  nodules  were  felt  in  different  portions  of  the  peritoneum;  in 
the  median  line  and  around  the  umbilicus  was  a  loosely  encapsulated  white  lump 
the  size  of  a  shellbark  nut.  This  was  not  removed,  on  account  of  the  presence  of 
secondary  nodules.  The  liver  was  covered  with  whitish  nodules,  similar  in  char- 
acter;  these  extended  from  the  liver  down  to  the  umbilicus. 

Path.  No.  8.  The  specimen  consists  of  the  ovary,  tube,  and  a  portion  of  the 
broad  ligament.  The  ovary  is  very  much  enlarged  and  contains  three  or  four  cysts. 
The  surface  is  irregular  in  outline.  There  is  a  dense,  hard  capsule  with  several 
small  cysts  showing  through  the  outer  surface.  At  the  inner  end  of  the  ovary  is  a 
cyst,  2  cm.  in  diameter,  filled  with  clear,  watery  fluid.  The  cysts  are  confined  to  the 
superficial  portion  of  the  ovary.     On  section,  the  greater  portion  of  the  mass  appears 

*  Liveing:  The  Lancet,  1875,  ii,  8. 

t  Gueneau  de  Mussy :  Cancer  du  peritoine.     Clin,  med.,  Paris,  1875,  ii,  28. 


432 


THE    UMBILICUS    AND    ITS    DISEASES. 


to  be  made  up  of  translucent,  grayish  tissue  having  an  edematous  appearance,  and 
running  through  this  in  every  direction  is  dense  fibrous  tissue.  There  are  ecchy- 
motic  patches  here  and  there  throughout  the  specimen.  The  broad  ligament  is 
thickened  and  contains  numerous  hard  masses  varying  from  a  pin-head  to  a  lima 
bean  in  size.  On  histologic  examination  the  matrix  of  the  tumor  is  found  to  con- 
sist of  very  edematous  fibrous  tissue.  Scattered  sparsely  or  abundantly  throughout 
the  stroma  are  colonies  of  carcinomatous  glands.  The  gland  type  in  some  areas  is 
very  well  preserved.     At  other  points  the  carcinoma  seems  to  form  solid  masses. 


£9 


m 


£* 


Fig.  185. — Carcinoma  of  the  Umbilicus  Secondary  to  Carcinoma  of  the  Ovaries. 
Gyn.  No.  6150;  Path.  No.  2407.  The  umbilicus  has  been  converted  into  a  round,  ulcerated  area,  with  sharp  edges 
and  a  granular  base.  The  picture  is  taken  from  the  indurated  tissue  near  the  edge  of  the  ulcer.  To  the  left  is  squamous 
epithelium,  which  in  places  is  much  thickened,  but  in  the  upper  part  of  the  picture  is  normal  in  thickness.  On  the 
surface  is  some  exfoliated  and  partly  hornified  epithelium.  Immediately  beneath  the  skin  the  stroma  shows  consider- 
able small-round-cell  infiltration.  The  right  half  of  the  field  consists  of  nests  of  cancer-cells.  The  floor  of  the  ulcer 
to  a  large  extent  is  made  up  of  cancerous  tissue.  In  many  portions  of  the  growth  the  typical  glandular  character  of 
the  tumor  was  evident.     It  was  an  adenocarcinoma. 


There  is  no  trace  of  ovarian  stroma  remaining.  The  growth  is  a  virulent  adeno- 
carcinoma of  the  ovarjr.  It  is  exceptional  with  such  an  early  tumor  to  find  such 
wide-spread  metastases.  The  nodule  at  the  umbilicus,  although  not  examined 
histologically,  was  undoubtedly  similar  in  origin.  Whether  the  umbilical  growth 
was  due  to  extension  upward  from  below  or  from  above  is  problematic,  but  with 
metastases  in  the  liver  and  extending  down  along  the  suspensory  ligament  to  the 
umbilicus  it  looks  very  much  as  if  the  growth  were  secondary  to  the  liver  nodules. 

Adenocarcinoma     of     the     Ovary;     Metastases     to     the 
Peritoneum    and    to    the    Umbilicus.  —  Gyn.  No.  6150.     A.   H., 


CARCINOMA    OF    THE    UMBILICUS.  433 

admitted  to  the  Johns  Hopkins  Hospital  June  6,  1898.  The  patient,  fifty-five  years 
of  age,  was  married  twenty-six  years  ago.  She  has  had  no  children  and  no  mis- 
carriages. The  present  illness  began  over  a  year  ago.  She  has  gradually  grown 
weaker,  and  has  not  been  able  to  work  for  a  long  time.  She  complains  of  abdominal 
enlargement,  of  marked  constipation,  and  of  a  growth  at  the  umbilicus. 

At  operation  the  parietal  peritoneum  was  studded  with  small,  whitish  eleva- 
tions, and  the  abdominal  cavity  contained  several  cystic  masses  reaching  to  the 
umbilicus.  They  could  not  be  removed.  The  umbilicus  itself  had  been  converted 
into  a  round,  ulcerated  area  with  sharp  edges  and  a  granular  base.  This  was 
excised  when  the  abdomen  was  opened.  The  patient  was  much  relieved  by  the 
operation  and  the  tenderness  over  the  abdomen  disappeared. 

Path.  No.  2407.  The  specimen  consists  of  fluid  from  the  peritoneal  cavity,  of  a 
small  section  of  a  cyst  wall,  and  of  the  umbilicus. 

Section  from  the  Umbilicus. — The  skin  surrounding  the  umbilicus  is  perfectly 
normal.  As  one  approaches  the  area  of  ulceration  it  is  raised  somewhat  and  becomes 
thickened,  and  the  papillae  extend  a  certain  distance  downward.  The  tissue  beneath 
the  squamous  epithelium  is  normal,  but  as  one  approaches  the  area  of  ulceration  it 
shows  small-round-cell  infiltration  around  the  capillaries.  Near  the  edge  of  the 
ulcerated  area  one  finds  nests  of  epithelial  cells  which  have  retracted  somewhat 
from  the  surrounding  stroma  (Fig.  185) .  In  certain  areas  one  can  make  out  a  defi- 
nite gland  arrangement.  The  growth  is  an  adenocarcinoma  with  a  tendency  to 
form  solid  nests.  As  one  passes  to  the  ulcer,  the  squamous  epithelium  disappears. 
The  surface  is  covered  with  fibrin,  polymorphonuclear  leukocytes,  and  small  round- 
cells.  The  nuclei  of  the  cancer-cells  vary  considerably  in  size.  Some  cancer-cells 
are  large,  stain  deeply,  and  contain  irregular  masses  of  chromatin.  The  entire 
floor  of  the  ulcer  is  made  up  of  granulation  tissue  and  nests  of  cancer-cells.  The 
line  of  junction  between  the  surface  epithelium  and  the  cancer  is  very  sharply  defined. 
In  the  depth  of  the  ulcer  the  tissue  consists  almost  entirely  of  nests  of  cancer-cells. 
The  process  has  undoubtedly  extended  up  from  the  abdomen  as  a  wedge  and  raised 
the  squamous  epithelium.  Over  the  area  of  carcinoma  the  skin  has  given  way  and 
an  ulcer  has  resulted.  The  umbilical  growth  is  identical  in  character  with  the 
ovarian  tumor  from  which  it  originated. 

After  the  book  was  in  type  and  shortly  before  going  to  press  the  following  inter- 
esting case  came  under  my  care : 

Adenocarcinoma  in  the  Omentum  Incarcerated  in 
an  Old  Umbilical  Hernia  (Plate  V).  —  The  primary 
growth  was  apparently  in  the  ovary,  possibly  in  the 
uterus.  Mrs.  Annie  E.,  aged  seventy- two,  referred  to  me  by  Dr.  Albert  Singe- 
wald,  was  admitted  to  the  Church  Home  and  Infirmary  September  28, 1915.  The 
patient  had  had  two  children  and  one  miscarriage.  The  menopause  had  occurred 
at  forty. 

Present  Illness. — About  four  years  before  she  had  noticed  vaginal  bleeding, 
which  had  persisted  up  to  the  time  of  admission.  For  the  last  two  or  three  months 
she  had  had  profuse  bleeding,  lasting  from  three  to  four  days.  Between  these 
attacks  there  had  been  a  continuous  thin,  pinkish  discharge.  For  the  last  two 
months  she  had  suffered  a  great  deal  with  pain  over  the  sacrum  and  in  the  lower  ab- 
domen, and  during  the  same  time  there  had  been  pain  on  voiding.  She  had  lost  25 
pounds  within  the  last  two  months. 
29 


434  THE    UMBILICUS    AND    ITS    DISEASES. 

The  patient  was  a  very  large  woman,  weighing  235  pounds.  She  looked  rela- 
tively well.  On  physical  examination  the  abdomen  was  found  much  distended, 
but  there  was  some  laxness  in  both  flanks.  An  umbilical  hernia  (Plate  V)  was 
noted,  which  presented  a  somewhat  unusual  appearance.  It  seemed  somewhat 
lobulated,  and  the  umbilicus  itself  was  crescentic.  The  entire  raised  area  measured 
about  5  cm.  from  above  downward  and  about  4  cm.  from  side  to  side.  It  did  not 
present  the  uniformity  of  outline  so  frequently  noted  in  umbilical  hernise.  On 
palpation  it  felt  hard,  and  one  could  detect  definite  nodular  thickenings  in  the  hernial 
mass.  These  were  apparently  four  or  five  in  number,  and  immediately  suggested 
metastatic  nodules. 

On  carefully  questioning  the  patient  we  learned  that  she  had  had  an  umbilical 
hernia  since  she  was  forty;  in  other  words,  for  thirty-two  years.  During  the  last 
three  months  she  had  noticed  that  the  hernia,  which  hitherto  had  been  quite  soft, 
had  become  gradually  hard  and  nodular. 

On  abdominal  palpation  a  definite  tumor  mass  could  be  felt  to  the  left  of  the 
umbilicus.  Its  exact  dimensions  could  not  be  determined  on  account  of  the  ab- 
dominal distention.     In  either  flank  fluctuation  could  be  elicited. 

I  kept  the  patient  in  the  ward  several  days,  while  debating  whether  any  operative 
procedure  should  be  undertaken.  She  was  so  anxious  for  relief  that  I  finally  con- 
sented to  make  an  exploratory  incision. 

Operation  October  1,  1915. — An  elliptic  incision  was  made  around  the  enlarged 
and  nodular  umbilicus,  and  in  the  abdominal  muscles  just  above  the  umbilicus 
was  found  a  definite  nodule,  about  1  x  1.5  cm.  After  the  umbilical  growth  had  been 
freed  from  the  abdominal  wall,  a  tongue  of  omentum  was  discovered  that  passed 
into  the  hernial  sac.  This  portion  of  omentum  was  intimately  blended  with  the 
umbilicus  and  was  removed  with  the  sac.  The  parietal  peritoneum  everywhere 
was  studded  with  carcinomatous  nodules  varying  from  1  to  6  mm.  in  diameter.  To 
the  left  of  the  umbilicus  was  an  ovarian  tumor  which  appeared  to  be  about  16  cm. 
in  diameter.  The  omentum  was  markedly  thickened,  and  the  greater  part  of  it  lay 
rolled  up  above  the  umbilicus.  Loops  of  small  bowel  were  adherent  to  the  anterior 
abdominal  wall  near  the  symphysis,  and  also  at  other  points,  and  here  and  there, 

plate  v. 

Cancer  op  the  Umbilicus  Apparently  Secondary  to  a  Tcmor  of  the  Ovary. 

Gyn.-Path.  No.  21554.     Mrs.  A.  E. 

Fig.  1  gives  the  general  relations  as  found  at  operation.  At  the  umbilicus  was  the  hard  umbilical  hernial  mass 
containing  cancerous  nodules,  and  at  operation  a  cancerous  nodule  was  found  in  the  mid-line  just  above  the  umbilicus. 

To  the  left  of  the  umbilicus  was  an  ovarian  tumor  apparently  cystic.  The  greater  part  of  the  omentum  was  rolled 
up  and  formed  a  tumor  mass  about  midway  between  the  xiphoid  and  the  umbilicus.  As  there  was  a  general  peritoneal 
carcinosis  and  many  adhesions,  a  more  extended  examination  wras  not  made. 

Fig.  2  is  an  exact  drawing  of  the  umbilicus  as  it  appeared  before  operation.  The  umbilical  area  is  sharply  raised 
from  the  surrounding  abdominal  walls,  and  the  umbilical  depression  is  represented  by  a  crescentic  slit.  In  this  tumor 
four  or  five  very  hard  nodules  could  be  distinctly  made  out,  at  once  suggesting  malignancy. 

Fig.  3  graphically  depicts  the  condition  noted  when  the  abdomen  was  opened.  Occupying  the  left  side  of  the 
lower  abdomen  is  an  ovarian  cyst.  This  below  and  posteriorly  is  adherent.  The  omentum  above  the  umbilicus  is 
greatly  thickened  as  a  result  of  involvement  in  the  carcinomatous  process. 

The  lower  end  of  the  omentum  fills  the  umbilical  hernial  sac.  This  portion  of  the  omentum  is  also  much  thickened 
and  has  become  intimately  blended  with  the  hernial  walls.  The  incarcerated  omentum  is  riddled  with  cancer.  In  the 
lower  part  of  the  omentum,  that  lies  in  t  lie  hernia,  is  a  small  cyst. 

F  i  g  .  4  shows  a  longitudinal  section  of  the  umbilical  tumor.  Between  a  and  a'  we  see  small  carcinomatous  nodules 
in  the-  parietal  peritoneum  of  the  anterior  abdominal  wall.  The  omentum  (6)  projects  into,  completely  fills,  and  is 
intimately  blended  with  the  hernial  sac.  In  the  upper  part  of  the  picture,  where  a  catgut  ligature  is  seen,  the  omental 
fat  can  still  be  fairly  well  recognized,  but  most  of  the  omentum  in  the  hernia  looks  very  much  like  fibrous  tissue.  It  was 
everywhere  invaded  by  adenocarcinoma.  The  cyst  (c)  was  lined  with  one  or  more  layers  of  cancer  cells,  d  indicates 
the  lower  limit  of  the  hernial  sac;  e  is  the  bottom  of  the  crescentic  umbilical  slit  seen  in  Fig.  2. 


CARCINOMA    OF    THE    UMBILICUS. 


435 


PLATE  V. 
Cancer  of  the  Umbilicus  Apparently  Secondary  to  a  Tumor  of  the  Ovary. 


* : .  ;         i        &  v :.  -  \  I  a    .     ■'    \n° 

i  fete"1™  \)- 


Carcinomatous 
nodule 


■  ' 


Peritoneum 


Ornenium 


a...     i 


a' 


436  THE    UMBILICUS    AND    ITS    DISEASES. 

where  such  adhesions  existed,  the  bowel  was  covered  over  with  flakes  of  fibrin. 
Further  examination  being  impossible,  the  abdomen  was  closed  as  soon  as  the  um- 
bilical growth  had  been  removed. 

The  patient  rallied  remarkably  well  and  left  the  hospital  on  October  23,  feeling 
very  much  relieved. 

Gyn.-Path.  No.  21554.  Sections  involving  the  entire  hernial  mass  show  that 
the  omentum  which  had  extended  into  the  hernia  has  become  blended  with  the  walls 
of  the  hernial  sac,  and  that  very  little  adipose  tissue  remains,  the  stroma  consisting 
almost  entirely  of  fibrous  tissue,  rich  in  spindle  cells  (Plate  V,  Fig.  4).  Scattered 
through  this  are  many  glands  occurring  singly  or  in  groups.  In  some  places  they 
are  lined  with  one  layer  of  epithelium,  the  cells  being  somwhat  cuboidal  or  roundish 
and  manifesting  a  tendency  to  drop  off.  In  other  places  there  are  colonies  of  glands, 
some  of  the  gland-spaces  being  partially  or  completely  filled  with  epithelial  cells. 
The  nuclei  of  the  epithelial  cells  vary  markedly  in  size.  Some  of  them  contain  large 
masses  of  deeply  staining  chromatin.  The  picture  is  that  of  an  adenocarcinoma  of  a 
type  usually  noted  in  the  ovary.  The  cyst-like  space  noted  at  one  end  of  the  um- 
bilicus is  lined  with  epithelium.  In  some  places  this  is  almost  flat;  in  other  places 
it  is  drawn  up  in  papillary-like  folds.  In  this  case  we  have  a  definite  adenocarci- 
noma of  the  umbilicus. 

From  the  foregoing  it  is  perfectly  clear  that  the  primary  cancer  was  either  in  the 
ovary  or  in  the  uterus.  The  type  of  gland  found  in  the  carcinoma  might  well  have 
been  from  either  the  body  of  the  uterus  or  from  the  ovary.  Uterine  hemorrhage 
extending  over  a  period  of  four  years  is  somewhat  unusual  in  so  old  a  patient  unless 
some  serious  uterine  trouble  exists.  On  the  other  hand,  we  all  know  that  uterine 
hemorrhage  is  not  infrequently  associated  with  an  ovarian  tumor. 

The  presence  of  the  ovarian  tumor,  with  apparently  thick  walls,  would  strongly 
suggest  the  ovary  as  the  primary  seat  of  the  trouble.  Further,  metastases  from  an 
ovarian  carcinoma  are  not  uncommon.  Peritoneal  metastases  of  such  a  character 
following  a  carcinoma  of  the  body  of  the  uterus  I  have  never  seen. 

In  all  probability,  then,  this  patient  had  a  primary  carcinoma  of  the  left  ovary; 
general  peritoneal  metastases  had  developed,  and  finally  the  omentum  in  the  um- 
bilical hernia  had  been  invaded  by  carcinomatous  nodules.  Here  they  could  be 
palpated  with  the  utmost  ease. 

LITERATURE  CONSULTED  ON  CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO 

OVARIAN  CARCINOMA. 
Aslanian,  G.:  Contribution  a  P etude  de  la  peritonite  cancereuse.     These  de  Paris,  1895,  No.  150. 
Burkhart,  0.:  Ueber  den  Nabelkrebs.     Inaug.  Diss.,  Berlin,  1889. 
Cullen,  Thomas  8.:   Gyn.  Xo.  2004,  from  the  records  of  the  Johns  Hopkins  Hospital;   Gyn.  No. 

0150,  from  the  records  of  the  Johns  Hopkins  Hospital. 
Cullen,  Thomas  S. :  Cancer  of  the  Uterus,  1900. 
Demons  el    Verdelet:    Cancer  secondaire  de  Pombilic.     Congr.  periodique  de  gyn.,  d'obstet.  et 

de  paod.,  1898,  ii,  344. 
Gueneau  de  Mussy:  Cancer  du  peritoine.     Clin,  med.,  1875,  ii,  28. 
Liveing:  Cancer  of  Ovaries  and  Peritoneum  and  Umbilicus.     The  Lancet,  1875,  ii,  8. 

CARCINOMA  OF  THE  UMBILICUS  SECONDARY  TO  CARCINOMA  OF  THE  UTERUS. 

Extension  of  carcinoma  of  the  uterus  to  the  umbilicus  is  exceptionally  rare.     In 

the  examination  of  an  unusually  large  number  of  cases  of  uterine  cancer  I  have 


CARCINOMA    OF    THE    UMBILICUS.  437 

never  detected  an  umbilical  involvement.  Le  Coniac,*  in  his  thesis  on  cancer  of  the 
umbilicus  secondary  to  primary  uterine  or  ovarian  growths,  says  that  in  one  case 
there  existed  between  the  cancer  of  the  uterus  and  the  umbilical  tumor  a  chain  of 
nodules  along  the  anterior  abdominal  wall. 

Catteau,t  in  his  thesis  in  1876,  described  the  case  of  a  young  woman  who  had 
carcinoma  of  the  body  of  the  uterus.  There  were  two  nodules  in  the  abdomen  and 
a  tumor  the  size  of  a  filbert  at  the  umbilicus.  The  inguinal  glands  were  enlarged. 
In  this  case  the  umbilical  growth  was  in  all  probability  secondary  to  that  in  the 
uterus.  These  are  the  only  two  cases  that  I  can  find  in  any  way  suggesting  cancer 
of  the  umbilicus  secondary  to  a  primary  growth  in  the  uterus. 

Quenu  and  Longuet,J  however,  in  their  paper  mention  two  cases  of  cancer  of 
the  uterus  with  secondary  nodules  at  the  umbilicus. 

CASES  OF  SECONDARY  CARCINOMA  OF  THE  UMBILICUS  IN  WHICH  THE  SOURCE 
OF  THE  PRIMARY  GROWTH  WAS  NOT  DETERMINED. 

These  cases  closely  resemble  those  of  secondary  carcinoma  of  the  umbilicus 
already  considered.  A  few,  however,  present  particularly  well  some  of  the  salient 
points  and  other  features  not  illustrated  by  the  preceding  cases. 

In  Bantigny's  case  a  small,  ovoid,  sessile  nodule  was  present  at  the  umbilicus. 
The  inguinal,  axillary,  and  subclavicular  glands  on  both  sides  were  implicated. 

In  Chuquet's  Case  3,  at  the  umbilicus  was  a  cancerous  plaque,  10  by  5  cm., 
which  was  continuous  with  the  induration  in  the  suspensory  ligament. 

My  case  (G)  was  unusual,  in  that  the  umbilical  changes  had  become  apparent 
exceptionally  early,  there  being  merely  a  delicate  papillary  growth  in  the  umbilical 
depression.  This  growth  on  section  clearly  shows  the  fibrous  appearance  of  these 
tumors  (Fig.  188,  p.  441).  The  specimens  from  three  others  of  these  cases  came 
under  my  personal  attention.  In  Dr.  W.  T.  Willey's  case  the  growth  was  bluish 
red  and  very  prominent,  as  seen  in  Fig.  186,  p.  439.  It  showed  areas  of  ulceration. 
Operation  was  contraindicated,  and  we  were  unable  to  get  an  autopsy.  In  Irving 
Miller's  case  the  umbilical  growth  reached  the  surface  of  the  umbilicus.  Haggard's 
case  is  particularly  striking  on  account  of  the  large  dimensions  of  the  umbilicus 
(Fig.  190,  p.  443),  its  general  contour  being  still  preserved.  This  tumor  on  section 
also  clearly  showed  the  apparent  fibrous  character  of  these  growths.  The  carcino- 
matous structure  would  not  for  a  moment  be  suspected  from  such  a  picture. 

Secondary  Carcinoma  of  the  Umbilicus.  —  Bantigny's 
patient,  §  a  man  fifty-three  years  of  age,  six  months  before  coming  under  observation, 
had  noticed  a  tumor  the  size  of  a  pea  in  the  center  of  the  umbilical  depression.  His 
digestion  had  been  poor  for  some  time,  and  he  had  had  radiating  pains  in  the 
umbilical  region.  There  had  been  loss  of  appetite  and  progressive  emaciation  for 
two  months.  At  the  time  of  operation  the  umbilical  nodule  was  the  size  of  a  small 
walnut,  ovoid  in  form,  and  with  a  broad  pedicle.  It  was  purple  in  color,  ulcer- 
ated, but  apparently  movable.  The  inguinal  glands  on  both  sides  were  enlarged. 
The  subclavicular  and  axillary  glands  were  also  involved. 

*  Le  Coniac,  H.  C.  J. :  Cancer  secondaire  de  l'ombilic,  consecutif  aux  tumeurs  malignes  de 
l'appareil  utero-ovarien.     These  de  Bordeaux,  1898,  No.  19. 

f  Catteau,  J.  F. :  De  l'ombilic  et  de  ses  modifications  dans  les  cas  de  distension  de  l'abdomen. 
These  de  Paris,  1876. 

X  Quenu  et  Longuet:  Du  cancer  secondaire  de  l'ombilic.     Rev.  de  chir.,  1896,  xvi,  97. 

§  Bantigny,  A. :  Un  cas  de  cancer  de  l'ombilic.     Jour,  des  sci.  med.  de  Lille,  1898,  2.  s.,  xxi,  91. 


438  THE    UMBILICUS    AND    ITS   DISEASES. 

At  operation  the  omentum  was  found  adherent,  and  at  its  extremity  was  a  small 
tumor  the  size  of  a  pea,  hard,  and  manifestly  cancerous.  Bantigny  held  that  the 
umbilical  cancer  was  secondary  to  some  visceral  growth. 

Carcinoma  of  the  Umbilicus  Secondary  to  Peritoneal 
Carcinosis.  —  Chuquet*  bases  his  paper  on  general  carcinosis  of  the  peri- 
toneum on  46  cases. 

Case  3. — A  woman,  sixty  years  of  age,  two  and  one-half  months  before,  had 
begun  to  complain  of  severe  pain  in  the  legs  and  in  the  inguinal  region.  At  that 
time  a  painful,  hard,  and  ulcerated  enlargement  at  the  umbilicus  had  been  noticed. 
The  ulceration  was  superficial  and  covered  with  a  crust  which  dropped  off  at  inter- 
vals.    At  the  same  time  she  had  had  a  diarrhea  lasting  three  weeks. 

The  abdomen  was  enlarged,  and  on  examination  an  area  of  induration,  5  by  6 
cm.,  could  be  felt  at  the  umbilicus,  and  in  the  abdomen  hard  masses  could  be 
detected.     Several  glands  were  palpable  in  the  inguinal  region. 

At  autopsy  several  liters  of  ascitic  fluid  were  found.  The  intestines  were  studded 
with  small  cancerous  nodules.  A  large  tumor  was  present  in  the  omentum,  which 
was  adherent  to  the  anterior  surface  of  the  stomach.  At  the  umbilicus  was  an 
indurated  plaque,  10  cm.  long  by  5  cm.  broad,  continuous  with  an  induration  in  the 
suspensory  ligament  of  the  liver.  The  ulceration  of  the  umbilicus  was  only  super- 
ficial. Nodules  were  present  in  the  pelvis  and  the  liver.  The  mucosa  of  the  stom- 
ach had  not  been  invaded. 

[Of  course,  in  this  case  the  primary  site  is  still  in  doubt. — T.  S.  C] 

A  Malignant  Growth  of  the  Umbilicus,  Apparently 
a  Carcinoma  Secondary  to  Some  Abdominal  Growth. 
—Mrs.  J.  J.,  aged  eighty,  seen  in  consultation  with  Dr.  W.  T.  Willey,  October  5, 
1910.  This  patient  has  had  indigestion  for  years,  more  marked  during  the  last  few 
months.  She  rises  early  for  her  breakfast  and  then  goes  to  bed  for  several  hours 
on  account  of  the  uncomfortable  sensation  in  the  abdomen.  For  about  ten  years 
she  has  had  uterine  hemorrhages  at  irregular  intervals.  Her  chief  complaint  is 
of  pain  and  enlargement  at  the  umbilicus. 

Examination. — The  umbilicus  is  rolled  out  and  its  right  side  is  occupied  by  a 
bluish-red  nodule,  3.5  cm.  in  diameter  (Fig.  186).  This  presents  a  glazed  appear- 
ance. In  some  places  it  is  covered  over  with  skin,  but  at  a  few  points  are  little 
areas  of  ulceration,  which,  however,  do  not  bleed  much.  If  one  attempts  to  roll  the 
tumor  out  of  the  umbilicus,  some  pus  escapes  from  the  crevices.  Surrounding  the 
umbilicus  is  a  zone  of  induration  about  1  cm.  in  diameter.  The  umbilical  tumor 
seems  to  be  fairly  well  fixed. 

On  pelvic  examination  the  uterus  is  found  to  be  about  four  times  the  natural 
size.     The  cervix  is  normal. 

It  looks  very  much  as  if  the  growth  at  the  umbilicus  is  a  carcinoma,  and  that 
it  is  secondary  to  some  abdominal  growth.  It  is  just  possible  that  it  may  come 
from  a  carcinoma  of  the  body  of  the  uterus,  but  it  is  more  probable  that  it  is  second- 
ary to  some  growth  in  the  stomach. 

After  considering  the  matter  fully  I  decided  against  operation  on  account  of  the 
patient's  age,  and  because  there  existed  some  inoperable  growth  in  the  abdomen. 
The  patient  died  a  few  months  after  my  visit.     No  autopsy  was  permitted. 
*  Chuquet,  A. :  Du  carcinome  generalise  du  peritoine.     These  de  Paris,  1879,  No.  548. 


CARCINOMA    OF    THE    UMBILICUS. 


439 


Carcinoma  of  the  Umbilicus  Secondary  to  an  Abdom- 
inal Growt  h  .  (Personal  communication  from  Dr.  Irving  Miller.) — E.  M. 
was  operated  on  at  the  Church  Home  and  Infirmary  on  August  31,  1909.  She 
was  a  woman  fifty-eight  years  of  age,  married,  and  had  had  one  child.  At  the  lower 
end  of  the  umbilical  depression  was  a  painless  growth  the  size  of  a  lentil,  grayish  red 
in  color.  There  was  a  considerable  amount  of  moisture.  No  nodule  could  be 
detected  in  the  abdomen,  and  the  patient  had  no  indigestion.  During  the  removal 
of  the  growth  nodules  were  found  in  the  omentum  and  mesentery.     These  varied 


w    V 


Fig.  186. — A  Malignant  Growth  of  the  Umbilicus,  Apparently  a  Carcinoma  Secondary   to  Some  Abdomi- 
nal Growth. 
This  photograph  of  Dr.  Willey's  patient  was  made  by  Dr.  Cecil  Vest.     A  growth  occupies  the  site  of  the  umbilicus; 
this  is  several  centimeters  broad,  as  indicated  by  comparing  it  with  the  fingers.     The  skin  is  still  intact,  but  very  thin, 
and  over  the  dark  areas  is  almost  wanting. 


from  the  size  of  a  pea  to  that  of  a  hazelnut.  The  peritoneum  was  free  and  there 
was  no  hernia. 

Dr.  Miller  thought  that  the  umbilical  growth  was  secondary,  but  could  not 
locate  the  original  tumor.     It  did  not  emanate  from  the  pelvis. 

Path.  No.  14122.  The  specimen  measures  3  by  1  cm.,  and  consists  of  tissue 
covered  over  with  skin.  Occupying  the  umbilical  region  is  a  firm  nodule  which, 
on  section,  has  a  whitish,  fibrous  appearance.  The  entire  specimen  resembles  a 
large  umbilicus. 

On  histologic  examination  the  squamous  epithelium  in  the  vicinity  of  the  umbil- 
icus is  perfectly  normal  and  the  underlying  stroma  unaltered.     It  ends  abruptly, 


440 


THE    UMBILICUS   AND    ITS    DISEASES. 


and  coming  up  from  below  and  reaching  the  surface  is  a  cancerous  growth  (Fig. 
187).  This  is  glandular  in  character,  and  consists  of  long,  finger-like  folds  or  of 
papillary  masses  or  groups  of  glands.  The  cells  are  very  regular,  but  mitotic  figures 
are  very  abundant.  Only  at  one  point  over  a  very  limited  area  is  the  skin  lack- 
ing. Here  the  cancerous  tissue  reaches  the  surface.  It  is  covered  with  a  moderate 
amount  of  fibrin  in  which  are  a  few  leukocytes.  Certain  portions  of  the  tumor 
show  small  areas  of  calcification.  It  is  without  doubt  a  secondary  carcinoma  of 
the  umbilicus.     The  picture  present  resembles  very  closely  that  found  in  cancer  of 


Fig.  187. — Adenocarcinoma  of  the  Umbilicus  Secondary  to  an  Intra-abdominal  Growth. 
Gyn.-Path.  No.  14122.  (Specimen  sent  by  Dr.  Irving  Miller,  Baltimore.)  The  surface  on  the  left  is  covered  over 
with  squamous  epithelium,  which  shows  little  deviation  from  the  normal.  As  we  pass  to  the  right  the  squamous  epi- 
thelium gradually  disappears,  and  on  the  extreme  right  the  surface  is  composed  of  cancerous  tissue.  The  right  half  of 
the  picture  shows  a  definite  papillary  or  finger-like  character  of  the  growth.  It  is  an  adenocarcinoma.  Along  the  ad- 
vancing margins  of  the  cancer  the  stroma  shows  much  small-round-cell  infiltration. 


the  body  of  the  uterus.     It  is  impossible  for  us,  however,  to  determine  absolutely 
the  original  source  of  the  growth. 

Secondary  Carcinoma  of  the  Umbilicus;  Metastases 
in  the  Right  Inguinal  Glands.  —  Mr.  G.,*  forty-two  years  of  age, 
was  seen  in  consultation  August  30,  1904.  The  patient  was  well  nourished,  and 
complained  of  a  discharge  from  the  umbilicus.  Six  weeks  before  he  had  been  struck 
in  the  abdomen  with  a  shoe  and  the  umbilicus  had  commenced  to  discharge  three 
weeks  later.  The  umbilicus  itself  presented  a  granular  appearance  (Fig.  188)  and 
the  tissue  surrounding  it  was  indurated.     The  patient  had  had  dyspepsia  for  years; 

*  This  case  was  reported  by  me  in  the  Jour.  Amer.  Med.  Assoc.,  1911,  lvi,  391. 


CARCINOMA    OF    THE    UMBILICUS. 


441 


also  pain  in  the  lower  abdomen  over  the  appendix.  He  was  admitted  to  the  Church 
Home.  Under  anesthesia  the  inguinal  glands  were  carefully  palpated.  A  definite 
enlargement  was  found  in  the  right  side.  An  incision  10  cm.  in  length  was  made 
and  the  inguinal  glands  were  removed,  together  with  the  surrounding  fat.  I  then 
made  a  long  elliptic  incision  around  the  umbilicus  and  removed  the  umbilical  tumor, 
giving  the  hardened  area  a  wide  berth.  The  growth  at  the  umbilicus  closely 
resembled  a  retracted  nipple.  The  patient  took  the  anesthetic  badly,  and  conse- 
quently I  could  not  make  as  thorough  an  abdominal  exploration  as  I  desired.  With 
the  finger  carried  in  all  directions  I  was  unable  to  detect  any  thickening. 


Fig.  188. — Adenocarcinoma  of  the  Umbilicus. 
The  umbilicus  looks  very  much  like  an  inverted  carcinomatous  nipple.     The  margins  present  a  fine  nodular  ap- 
pearance.    The  dotted  line  indicates  the  limits  of  the  incision.    On  the  right  is  shown  a  longitudinal  section  through 
the  umbilicus.     There  is  much  thickening  due  to  carcinomatous  infiltration.     The  peritoneum  beneath  the  umbilicus 
was  free  from  adhesions.     (Gyn.-Path.  No.  7729.) 


Histologic  Examination. — Path.  No.  7729. — The  umbilical  growth  proved  to  be 
a  typical  adenocarcinoma.  The  squamous  epithelium  in  many  places  was  normal, 
but  along  the  edge  of  the  growth  it  was  impossible  to  distinguish  between  the  cells 
of  the  adenocarcinoma  and  those  of  the  squamous  epithelium.  There  was  as  yet 
little  breaking  down.  The  growth  in  the  inguinal  glands  macroscopicalfy  looked 
like  cancer  (Fig.  189).  On  histologic  examination  it  presented  exactly  the  same 
pattern  as  that  noted  at  the  umbilicus. 

On  January  25,  1905,  the  patient  was  in  fairly  good  health;  but  was  still  con- 
stipated and  had  great  difficulty  in  defecation.  On  February  24th  a  firm  globular 
mass  fully  10  cm.  in  diameter  was  found  occupying  the  middle  of  the  abdomen  and 


442 


THE    UMBILICUS    AND    ITS    DISEASES. 


the  left  inguinal  glands  were  considerably  enlarged.  The  umbilical  growth  was 
undoubtedly  secondary  to  the  intra-abdominal  cancer.  In  May,  1905, 1  again  saw 
the  patient.  His  bowels  had  not  moved  for  ten  days,  and  he  was  so  emaciated 
that  one  could  hardly  recognize  him.  Nodules  were  palpable  everywhere  in  the 
abdomen.     He  died  a  few  days  later. 

Cancer  of  the  Umbilicus.  —  Haggard  *  reports  the  case  of  a  man 
fifty-nine  years  of  age.  Three  months  before  admission  the  patient  had  noticed 
a  hard  nodule  the  size  of  a  hickory-nut  just  above  the  umbilicus.     The  hardness 

gradually  increased,  and  the  um- 
bilicus commenced  to  bulge.  The 
tumor  was  slightly  tender,  and 
there  was  a  sense  of  uneasiness;  it 
was  the  size  of  a  goose's  egg,  was 
stony  hard,  and  the  skin  could  not 
be  moved  over  it.  The  mass  was 
fixed.  The  patient  commenced  to 
lose  flesh. 

Haggard  removed  the  umbili- 
cus February  17,  1904,  making  an 
elliptic  incision.  The  resultant 
opening  gaped  nearly  as  large  as 
a  saucer.  The  stomach,  gall-blad- 
der, and  liver  were  examined  for 
cancer,  but  none  was  found.  The 
gall-bladder  was  very  hard  and 
thickened  and  contracted  down  on 
a  stone;  this  was  removed  and  the 
gall-bladder  drained.  The  perito- 
neum could  not  be  approximated. 
The  omentum  was  turned  up  and 
sewed  to  the  serous  margins  of  the 
incision.  With  considerable  diffi- 
culty the  fascia  and  muscle  were 
partly  brought  together  with  in- 
terrupted sutures  of  catgut.  The 
edges  of  the  wound  were  still  about 
13^  inches  apart.  The  silver  wire 
filigree  of  Willard-Bartlett  was 
used.  This  was  laid  on  corduroy  sutures  of  catgut,  the  edges  resting  between  the 
fat  and  the  fascia,  and  the  skin  was  closed.     The  wound  healed  without  incident. 

Secondary  Adenocarcinoma  of  the  Umbilicus. f  — 
Path.  No.  15029. — The  specimen  sent  me  by  Dr.  Haggard,  of  Nashville,  Tenn., 
in  April,  1910,  consists  of  the  umbilicus  with  a  good  deal  of  surrounding  tissue. 
The  entire  specimen  measures  10  cm.  in  length,  7  cm.  in  breadth.  The  umbilicus 
is  2.5  cm.  across  and  is  covered  with  skin.     It  presents  a  rather  uneven,  nodular 

*  Haggard,  W.  D. :  Cancer  of  the  Umbilicus.  Amer.  Jour.  Surg,  and  Gyn.,  St.  Louis,  1903- 
04,  xvii,  196. 

t  This  case  was  reported  by  me  in  Jour.  Amer.  Med.  Assoc,  1911,  lvi,  391. 


Fig.  189. — The  Section  Shows  Carcinoma  of  the  Right 
Inguinal  Glands. 
Scattered  throughout  the  adipose  tissue  are  several  solid 
areas.  Those  indicated  by  a  are  small  lymph-glands.  The 
lymph-gland  at  b  is  greatly  enlarged,  and  everywhere  infiltrated 
by  carcinoma  which  is  invading  the  surrounding  tissue;  c  is  also 
an  area  of  carcinoma.  Fig.  188  shows  the  umbilical  cancer  in 
the  same  case. 


CARCINOMA    OF    THE    UMBILICUS. 


443 


surface,  and  is  much  more  prominent  than  usual,  having  welled  up  in  the  center 
(Fig.  190).  There  is  no  evidence  of  ulceration  at  any  point.  On  section  the  dis- 
tance between  the  umbilicus  and  the  peritoneal  surface  is  2  cm.  The  tissues  look 
fibrous,  and  in  the  vicinity  of  the  umbilicus  show  infiltration,  apparently  with 
fibrous  tissue.  At  one  point  is  an  area  of  what  looks  like  localized  fibrous  thicken- 
ing, 2.5  cm.  in  diameter.  The  adipose  tissue  has  been  almost  entirely  replaced  at 
this  point. 


B. 


,.:■      .'  .  <^*.  }£<nHx^ 


Fig.  190. — Secondary  Carcinoma  of  the  Umbilicus.  (Natural  size.) 
Path.  No.  15029.  (Specimen  sent  by  Dr.  W.  D.  Haggard  of  Nashville,  Tenn.,  April,  1910.)  The  umbilical  fold  is 
much  widened,  and  the  umbilicus  is  shallower  than  usual.  It  presents  a  somewhat  uneven  and  nodular  appearance, 
but  is  everywhere  intact.  On  the  right  is  shown  a  longitudinal  section  through  the  umbilicus.  There  is  a  deep  cleft 
along  the  skin  surface,  and  the  umbilical  fold  is  deeper  than  usual.  The  fat  in  the  depth  has  been  replaced  to  a  large 
extent  by  fibrous  tissue,  which  is  everywhere  infiltrated  with  carcinoma.  The  peritoneal  surface,  which  is  to  the  left, 
is  perfectly  smooth;    there  is  no  evidence  of  any  adhesions. 


Histologic  Examination. — The  squamous  epithelium  is  intact,  and  there  is  pig- 
mentation in  the  deeper  layers,  suggesting  that  the  specimen  has  come  from  a 
colored  patient.  The  tissue  immediately  beneath  the  skin  in  some  places  is  normal; 
at  other  points  it  shows  some  small-round-cell  infiltration.  Scattered  everywhere 
throughout  the  thickened  fibrous  tissue  are  glands.  Some  of  them  are  small  and 
round,  others  elongated  or  tubular;  others  are  dilated.  The  glands  are  lined  with 
cylindric  or  cuboid  epithelium,  which  in  most  places  is  one  layer  in  thickness.     The 


444  THE    UMBILICUS    AND    ITS    DISEASES. 

nuclei  of  the  epithelial  cells  are  for  the  most  part  oval  and  stain  uniformly.  A  few 
of  the  epithelial  cells  have  very  large  and  deeply  staining  nuclei.  Where  the  glands 
are  dilated,  the  epithelium  tends  to  become  cuboid.  At  other  points  the  glands 
are  very  abundant,  are  undergoing  disintegration,  and  are  filled  with  mucus.  In 
some  places  the  epithelium  is  several  layers  in  thickness.  Here  and  there  gland 
epithelium  has  proliferated  to  such  an  extent  that  new  glands  are  being  formed. 
The  growth  is  undoubtedly  a  carcinoma  of  a  glandular  type  and  similar  to  one 
originating  either  in  the  stomach  or  intestine. 

Encephaloid  Cancer  of  the  Umbilicus.*  —  The  umbilicus 
of  an  old  man  was  occupied  by  a  tumor  the  size  of  a  fist,  and  presenting  a  bluish 
aspect.  It  was  apparently  adherent  to  the  peritoneum  and  to  the  skin  at  the 
umbilicus.  It  was  soft,  but  could  not  be  moved  at  all  without  displacing  the  abdom- 
inal wall.  The  patient  had  lancinating  abdominal  pains.  Demarquay  diagnosed 
cancer  of  the  umbilicus,  but  did  not  operate.     The  patient  died. 

Cancer  of  the  Umbilicus.  —  Demarquayf  with  Dr.  Roger  saw  a 
patient,  sixty  years  of  age,  who  had  a  soft  and  somewhat  fluctuating  tumor  at  the 
umbilicus.  It  was  the  size  of  two  hands.  It  had  originated  at  the  umbilicus.  It 
was  opened  at  several  points  and  fungating  masses  grew  from  it.  A  diagnosis  of 
encephaloid  cancer  was  made.  The  patient  died.  No  histologic  examination  is 
reported. 

Cancer  of  the  Omentum  and  Umbilicus  Simulating 
H  e  r  n  i  a  .  J  —  Mary  T.,  aged  sixty-six,  the  mother  of  four  children,  had  been  in 
good  health  until  four  years  previously,  when  she  had  noticed  a  projection  at  the 
umbilicus.  This  was  the  size  of  a  finger-tip,  and  was  pressed  on  by  her  stays.  The 
bowels  had  been  regular  until  one  month  before,  when  diarrhea  had  commenced. 
This  had  ceased  without  any  treatment,  but  had  returned  two  weeks  later,  accom- 
panied by  pain  in  the  abdomen,  especially  at  the  umbilicus.  Vomiting  had  then 
started,  and  the  patient  had  rapidly  grown  worse. 

After  admission  she  vomited  frequently.  The  vomitus  had  an  offensive  but 
non-fecal  odor.  The  patient  had  an  anxious  expression.  She  was  stout  and  well 
nourished;  the  abdomen  was  distended,  tympanitic,  and  tender.  There  was  a 
nodular  projection  in  the  left  half  of  the  umbilicus,  half  an  inch  in  diameter.  The 
overlying  skin  was  normal,  but  immediately  beneath  the  umbilicus  and  in  the 
abdominal  cavity  was  an  ill-defined,  very  hard,  slightly  movable  tumor,  apparently 
continuous  with  that  of  the  umbilicus.  The  patient  on  the  twelfth  day  developed 
a  temperature  of  104°  F.  and  died. 

Autopsy  showed  invasion  of  the  peritoneum  by  cancer.  The  mass  involving 
the  omentum  had  extended  into  the  umbilicus.  [This  case  at  first  simulated  a  small, 
strangulated  umbilical  hernia.  There  is  no  note  as  to  the  original  site  of  the 
cancer. — T.  S.  C] 

— .Carcinoma  of  the  U  m  b  i  1  i  c  u  s  .  §  —  A  stout  woman,  forty-nine 
years  of  age,  had  had  an  umbilical  hernia  for  a  long  time.  Six  months  before  she 
had  received  a  slight  injury  of  the  umbilicus,  and  from  that  time  the  hernia  had 

*  Demarquay:  Bull.  Soc.  de  chir.,  1870,  2.  ser.,  xi,  209.     Seance  du  8  Juin. 
f  Demarquay:   Op.  cit. 

%  Forster,  J.  Cooper:  Guy's  Hospital  Reports,  1874,  3.  s.,  xix,  4. 

§  Gallet,  M.  A. :  Epithelioma  de  l'ombilic.  Jour,  de  chir.  et  ann.  Soc.  beige  de  chir.,  Bruxelles, 
1901,  i,  565. 


CARCINOMA    OF    THE    UMBILICUS.  445 

increased  in  size.  On  admission  it  was  as  large  as  an  egg,  hard,  painful  on  pressure, 
and  irreducible. 

The  umbilical  growth  was  removed.  The  omentum  was  found  adherent,  and 
in  it  were  enormous  cancerous  masses.  Two  large  ovarian  cysts  were  removed  at 
the  same  time.  At  autopsy  gall-stones  were  found.  The  intestinal  tract  was 
normal.  Gallet  thought  the  cancer  was  primary  in  the  umbilicus.  No  micro- 
scopic examination,  however,  was  given,  as  the  case  was  reported  at  the  society  on 
the  day  of  the  operation. 

[The  umbilical  growth  was  probably  secondary. — T.  S.  C] 

Carcinoma  of  the  Umbilicus.  —  Kuster*  reports  a  case  personally 
communicated  to  him  by  Wilms.  An  old  Israelite  had  a  carcinoma  of  the  umbilicus 
and  died  in  consequence  of  digestive  disturbances.  The  general  history  suggests 
that  the  umbilical  growth  was  secondary. 

Cancer  of  the  Umbilicus. f  —  A  young  married  woman,  twenty- 
seven  years  of  age,  had  a  tuberculous  peritonitis  with  effusion.  In  the  region  of  the 
umbilicus  was  an  ulcerated  and  hemorrhagic  area.  McMurtry  opened  the  abdomen, 
evacuated  the  contents  and  took  the  umbilicus  out  through  an  elliptic  incision. 
He  diagnosed  the  case  as  one  of  fibroid  carcinoma. 

[In  the  absence  of  mention  of  a  microscopic  examination  a  possible  tuberculous 
character  of  the  umbilical  lesion  cannot  be  absolutely  excluded. — T.  S.  C] 

Carcinoma  of  the  Umbilicus.  J  —  A  man,  fifty-four  years  of  age, 
had  carcinoma  of  the  glands  of  the  left  groin  for  two  years  and  intra-abdominal 
symptoms  of  malignant  disease.  For  four  weeks  a  small,  very  painful,  fungating 
mass  had  been  developing  at  the  umbilicus.  The  umbilicus  as  a  whole  was  not 
enlarged  or  hardened.  From  its  center  sprang  a  tuft  of  purplish-red  granulation 
about  as  large  as  a  small  pea.  Morris  removed  the  umbilicus,  and  at  the  same  time 
made  an  exploratory  opening  for  examination  of  the  abdomen.  The  omentum  was 
the  seat  of  a  colloid  carcinoma,  but  there  were  no  adhesions  of  the  omentum  to 
furnish  a  route  for  infection  to  the  umbilicus.  The  umbilical  growth  was  an  adeno- 
carcinoma. 

Cancer  of  the  Umbilicus.  —  Nelaton§  speaks  of  a  scirrhus  of  the 
umbilicus  in  a  patient  sixty  years  of  age.  It  was  spheric,  regular,  about  2.5  cm.  in 
diameter.     No  microscopic  examination  was  made. 

Carcinoma  of  the  Umbilicus  Secondary  to  Abdominal 
Carcinoma.  |[  —  A  woman,  fifty-one  years  of  age,  had  had  an  abdominal 
enlargement  for  fifteen  months.  In  the  right  iliac  fossa  was  a  round  enlargement 
increasing  in  size.  Her  digestion  was  poor,  and  she  suffered  from  nausea  and  vomit- 
ing and  lost  weight.  Blood  and  pus  were  present  in  the  stools.  One  of  the  left 
inguinal  glands  was  enlarged  to  the  size  of  a  hazelnut.  The  point  of  origin  of  the 
tumor  was  not  certain.  At  the  umbilicus  was  also  a  carcinomatous  nodule  the  size 
of  a  walnut,  hard  and  purple  in  color.     In  the  vicinity  there  was  another  nodule. 

*  Kuster,  E. :  Die  Xeubildungen  am  Xabel  Erwachsener  unci  ihre  operative  Behancllung. 
Langenbeck's  Arch,  f .  klin.  Chir.,  1874,  xvi,  234. 

t  McMurtry,  L.  S.:  Louisville  Monthly  Jour,  of  Med.  and  Surg.,  1902-03,  ix,  492. 

t  Morris,  R.:  Lectures  on  Appendicitis  and  Xotes  on  Other  Subjects,  1S95,  96. 

§  Nelaton:  Squirrhe  ombilical.     Gaz.  des  hop.,  Paris,  1860,  xxxiii,  294. 

||  Xeveu,  V.:  Contribution  a  l'etude  des  tumeurs  malignes  secondares  de  l'ombilic,  Paris, 
1890,  No.  50. 


446  THE    UMBILICUS    AND    ITS    DISEASES. 

The  growth  was  an  adenocarcinoma.  Neveu  then  goes  on  to  give  a  general  resume 
of  the  subject. 

Secondary  Carcinoma  of  the  Umbilicus.  —  Pernice*  cites 
a  case  reported  by  Bergeat  (Inaug.  Dissert.,  Munich,  1883).  A  woman,  sixty-one 
years  old,  for  three  years  had  had  a  tumor  at  the  umbilicus  which  had  ulcerated. 
The  inguinal  glands  were  swollen.  At  autopsy  a  tumor  the  size  of  a  child's  head 
was  found,  which  projected  into  the  abdomen.  The  gall-bladder  was  adherent 
and  had  opened  into  the  tumor. 

Excision  of  Umbilicus  for  Malignant  Diseases. f  — 
The  patient,  thirty-seven  years  of  age,  was  thin  and  cachectic.  At  the  umbilicus 
was  a  nodule  the  size  of  a  hen's  egg.  It  had  been  growing  rapidly,  was  painful  and 
ulcerated.     Operation  was  advised,  but  the  patient  disappeared. 

Secondary  Carcinoma  of  the  Umbilicus. J  —  A  woman, 
fifty  years  of  age,  had  been  in  perfect  health  until  six  months  before,  when  she 
commenced  to  lose  her  appetite  and  have  vomiting  spells.  In  less  than  two  months 
she  had  lost  15  kilos.  A  month  before  admission  she  had  noticed  a  moderate-sized 
induration  at  the  umbilicus.  A  few  days  later  it  had  become  dark  red.  She  never 
had  had  any  pain.  The  umbilicus  was  removed.  No  tumor  was  detected  in  the 
abdominal  cavity.  The  specimen  consisted  of  a  violet-colored  mass  which  had 
ulcerated,  and  there  was  induration  of  the  surrounding  tissue.  On  cutting  through 
there  was  a  gritty-like  feel  suggestive  of  carcinoma.  The  peritoneum  covering 
the  under  surface  was  indurated,  but  smooth.  There  was  no  evidence  of  neoplasm 
in  the  abdomen.  On  histologic  examination  the  growth  proved  to  be  a  cylindric- 
cell  carcinoma.  From  the  findings  thus  far  the  tumor  might  have  been  considered 
as  primary.  Three  months  later,  however,  the  patient  was  suffering  from  hemor- 
rhage from  the  bowels.  The  inguinal  glands  on  both  sides  were  enlarged,  forming 
a  definite  mass.  The  patient  became  cachectic  and  soon  died.  The  umbilical 
growth  had  evidently  been  secondary. 

Quenu  and  Longuet  gave  the  following  data  concerning  cases  with  secondary 
carcinoma  of  the  umbilicus 

In  32  cases  in  which  the  sex  is  recorded,  23  of  the  patients  were  females — a 
proportion  of  70  per  cent.  (To  explain  this  Damaschino  expressed  the  opinion  that 
carcinoma  of  the  umbilicus  occurs  secondarily  to  carcinoma  of  the  uterus  or  the 
ovaries.)  In  19  out  of  36  cases  in  which  accurate  data  were  given,  the  primary 
growth  was  in  the  gastro-intestinal  tract.  Of  these  19  cases,  in  14  the  growth  was 
primary  in  the  stomach,  in  4  in  the  intestine,  and  in  1  in  the  stomach  and  intestine. 
In  two  cases  the  primary  cancer  was  in  the  uterus,  and  in  three  cases  the  original 
tumor  was  found  in  the  ovaries. 

Secondary  Carcinoma  of  the  Umbilicus.  —  Verchere§  gives 
a  short  review  of  the  literature  and  reports  the  case  of  a  woman,  fifty-five  years  of 
age,  who  for  several  days  had  had  signs  of  intestinal  obstruction.  Her  general 
health  up  to  that  time  had  been  good.  The  abdomen  was  distended,  and  at  the 
umbilicus  was  a  tumor  slightly  smaller  than  half  an  apple.     It  was  hard,  red, 

*  Pernice,  L. :  Die  Nabelgeschwtilste,  Halle,  1892. 
t  Parker,  Willard:  Arch.  Clin.  Surg.,  New  York,  1876-77,  i,  71. 

X  Quenu  et  Longuet:  Du  cancer  seconclaire  de  l'ombilic.     Rev.  de  chir.,  1896,  xvi,  97. 
§  Verchere:    De  hi  valeur  si'meiologique  du  cancer  de  l'ombilic.     Rev.  des  mah  cancereuses, 
1895-96,  i,  81. 


CARCINOMA    OF    THE    UMBILICUS.  447 

and  ulcerated,  but  on  the  surface  was  smooth  and  regular.  It  was  surrounded  by 
a  deep  funnel,  the  walls  of  which  were  composed  of  healthy  skin.  Verchere  thought 
it  was  a  secondary  growth,  and  made  a  rectovaginal  examination,  inquired  for 
gastric  and  intestinal  symptoms,  and  examined  the  anterior  surface  of  the  liver. 
All  these  examinations  gave  negative  results.  At  operation  he  found,  on  the  peri- 
toneum of  the  anterior  abdominal  wall,  many  small,  whitish-yellow,  cancerous 
nodules.  The  primary  source  of  the  abdominal  growth  which  had  given  rise  to  these 
metastases  and  to  the  secondary  carcinoma  at  the  umbilicus  could  not  be  located. 

Adenocarcin  o  m  a  of  the  Umbilicus.*  —  The  patient  was  sixty- 
eight  years  old,  and  for  nearly  a  year  had  had  discomfort  just  above  the  umbilicus. 
This  was  almost  continuous  and  was  independent  of  digestion.  At  the  umbilicus 
was  an  indurated  area  the  size  of  a  pigeon's  egg.  When  the  patient  came  under 
observation  the  induration  was  ovoid  in  form,  6  cm.  in  its  longest  diameter,  and  4 
cm.  broad.  It  seemed  to  be  a  primary  tumor  of  the  abdominal  wall.  It  was 
removed  but  the  patient  died  of  peritonitis. 

On  microscopic  examination,  according  to  Stori,  the  growth  proved  to  be  an 
adenocarcinoma. 

A  Retroperitoneal  Carcinoma  Associated  with  Cancer 
of  the  Umbilicus.  —  From  the  accompanying  history  it  appears  that  the 
primary  growth  was  retroperitoneal.  From  what  epithelial  structure  it  originated, 
it  is,  however,  impossible  to  say. 

MacMunn'st  patient  was  a  woman  sixty-three  years  of  age.  She  was  cachectic 
and  had  a  "mouse  smell. "  The  lymphatics  in  the  left  groin  were  of  stony  hardness 
and  considerably  enlarged.  At  the  umbilicus  was  a  hemispheric  tumor,  purplish 
in  color,  the  size  of  a  plum.  It  was  firm,  and  had  on  its  surface  two  small  ulcers. 
When  lifted  up,  the  tumor  could  readily  be  isolated  from  the  deeper  structures. 

At  autopsy  the  umbilical  growth  was  found  to  be  bluish  or  grayish  white  and 
hard;  it  projected  through  the  abdominal  wall,  raised  the  peritoneum  slightly,  but 
was  not  adherent  to  the  structures.  A  few  small,  whitish  nodules  were  found 
between  the  umbilicus  and  the  pubes.  The  omentum  contained  nodules,  the  largest 
23^  by  3^2  inch.  Secondary  growths  were  also  present  in  the  mesentery.  The 
umbilical  growth  was  undoubtedly  secondary  to  the  retroperitoneal  tumor. 

*  Stori,  Teodoro:  Contribute)  alio  studio  dei  tumori  dell'  ombelico.  Lo  Sperimentale,  Arch, 
di  biologia  normale  e  patologia,  1900,  liv,  25. 

f  MacMunn:  Case  of  Retroperitoneal  Cancer  Accompanied  by  Cancer  of  the  Navel.  Dublin 
Jour,  of  Med.  Sci.,  lxii,  1876,  1. 

LITERATURE  CONSULTED  ON  CASES  OF  SECONDARY  CARCINOMA  OF  THE  UMBILI- 
CUS IN  WHICH  THE  SOURCE  OF  THE  PRIMARY  GROWTH  WAS  NOT 

DETERMINED. 

Bantigny,  A. :  Un  cas  de  cancer  de  1'ombilic.     Jour,  des  sci.  med.  de  Lille,  1898,  2.  s.,  xxi,  91. 

Chuquet:  Du  carcinome  generalise  du  peritone.     These  de  Paris,  1879,  No.  548. 

Cullen,  Thomas  S. :  Dr.  W.  T.  Willey's  case:  Secondary  Carcinoma  of  the  Umbilicus. 

Cullen,  Thomas  S. :  Dr.  Irving  Miller's  case:  Secondary  Carcinoma  of  the  Umbilicus. 

Cullen,  Thomas  S.:   Personal  case. 

Cullen,  Thomas  S.:   Surgical  Diseases  of  the  Umbilicus.     Jour.  Amer.  Med.  Assoc,  February  11, 

1911,  lvi,  391. 
Haggard,  W.  D.:    Cancer  of  the  Umbilicus.     Amer.  Jour.  Surg,  and  Gyn.,  St.  Louis,  1903-04, 

xvii,  196. 


44"v  THE    UMBILICUS    AND    ITS    DISEASES. 

Deniarquay :  Cancer  de  l'ombilie.     Bull.  Soc.  de  chir.,  1S70,  2.  ser.,  xi,  209.     (Seance  du  8  Juin.) 
Forster,  J.  C:     Cancer  of  the  Omentum  and  Umbilicus  Simulating  Hernia.     Guy's  Hospital 

Reports,  1S74,  3.  s..  xix.  4. 
Gallet.  M.  A.:    Epitheliorue  de  l'ombilie.     Jour,  de  chir.  et  arm.  Soc.  beige  de  chir.,  Bruxelles, 

1901,  i,  565. 
Exist  er,  E.:  Die  Xeubildungen  am  Nabel  Erwachsener  und  ihre  operative  Behandlung.     Langen- 

beck's  Arch.  f.  klin.  Chir.,  1874,  xvi,  234. 
McMurtry,  L.  S.:   Cancer  of  the  Umbilicus.     Louisville  Monthly  Jour.  Med.  and  Surg.,  1902-03, 

ix,  492. 
Morris,  R.:    Carcinoma  of  the  Umbilicus.     Lectures  on  Appendicitis  and  Notes  on  Other  Sub- 
jects, 1S95,  96. 
Nelaton:   Squirrhe  ombihcal.     Gaz.  des  hop.,  Paris,  1860,  xxxiii,  294. 

Neveu,  V. :  Contribution  a  l'etude  des  tumeurs  mahgnes  secondaires  de  l'ombilie.     Paris,  1890. 
Pernice,  L.:    Die  Nabelgeschwulste,  HaUe,  1892. 
Parker,  W. :  Excision  of  Umbihcus  for  MaUgnant  Diseases.     Arch.  Clin.  Surg.,  New  York,  1876- 

77.  i.  71. 
Quenu  et  Longuet :  Du  cancer  secondaire  de  l'ombilie.     Rev.  de  chir.,  1896,  xvi,  97. 
Stori,  T. :    Contributo  alio  studio  dei  Tumori  dell'  ombelico.     Lo  Sperimentale,  Arch,  di  biologia 

normale  e  patologia,  1900,  liv,  25. 
Verchere,  F. :    De  la  valeur  semeiologique  du  cancer  de  l'ombilie.     Rev.  des  maladies   cancer- 

euses,  1895-96,  U,  81. 


CHAPTER  XXVI. 
SARCOMA  OF  THE  UMBILICUS. 

Telangiectatic  myxosarcoma. 

Spindle-cell  sarcoma  of  the  umbilicus:  report  of  cases. 

Round-cell  sarcoma  of  the  umbilicus. 

Melanotic  sarcoma  of  the  umbilicus. 

The  literature  on  this  subject  is  in  a  very  chaotic  condition.  From  the  recorded 
cases  it  is  possible  to  make  the  following  classification : 

1.  So-called  telangiectatic  myxosarcoma  occurring  at  or  near  the  time  of  birth. 
This  in  reality  is  not  malignant. 

2.  Spindle-cell  sarcoma. 

3.  Round-cell  sarcoma. 

4.  Melanotic  sarcoma. 

At  best  my  description  of  sarcoma  of  the  umbilicus  will  be  fragmentary  and 
incomplete.  I  shall  give  abstracts  of  the  more  characteristic  cases  recorded,  so  that 
the  reader  may  draw  his  own  conclusions.  After  careful  histologic  studies  of  such 
cases  in  the  future  it  is  to  be  hoped  that  before  many  years  the  subject  of  sarcoma 
of  the  umbilicus  will  be  placed  on  a  clear  and  satisfactory  basis. 


TELANGIECTATIC  MYXOSARCOMA. 

Cases  of  this  nature  have  been  reported  by  Virchow,  Kaufmann,  and  von  Winckel. 
In  1864  Gerdes  saw  a  child,  a  few  hours  old,  with  a  horn-like  projection  from  the 
umbilicus.  It  was  four  inches  in  length  and  about  the  thickness  of  the  index-finger, 
and  gradually  tapered  to  the  end.  At  first  it  was  bright  red  in  color,  later  dark.  It 
was  very  smooth,  had  an  abundant  blood-supply,  was  rather  firm,  had  no  pulsation, 
and  on  compression  did  not  diminish  in  size.  The  growth  was  composed  of  spindle- 
cells  separated  from  each  other  by  a  mucous  intercellular  substance.  Virchow 
termed  it  a  telangiectatic  myxosarcoma. 

In  Kaufmann's  case,  reported  in  1890  (Figs.  191  and  192),  the  tumor  was  like- 
wise present  at  birth,  and  in  the  course  of  a  few  days  was  observed  to  grow  gradually. 
It  projected  6  cm.  from  the  abdominal  wall  and  was  16  cm.  in  circumference.  It 
was  partly  covered  with  skin,  partly  with  amnion.  Its  outer  portion  was  dense; 
its  central  part  cavernous.  On  histologic  examination  the  former  was  found  to 
consist  of  spindle-cells,  the  latter  of  myxosarcomatous  tissue.  The  angiomatous 
appearance  in  the  central  portion  was  due  to  the  great  dilatation  of  the  arteries. 

Von  Winckel  in  1893  observed  a  red  tumor  at  the  umbilicus  in  a  new-born  child. 
This  tumor  (Fig.  194)  was  4  cm.  long,  and  at  the  umbilicus  2.8  cm.  in  diameter. 
It  was  bright  red  in  color.  Its  surface  was  covered  with  what  appeared  to  be  a 
hyaline  membrane.  The  growth  was  composed  chiefly  of  spindle-shaped  cells. 
There  was  an  abundance  of  large  blood-vessels,  and,  in  addition,  large  lymph- 
spaces.  At  certain  points  the  endothelium  of  the  lymph-spaces  had  proliferated. 
30  449 


450 


THE    UMBILICUS    AND    ITS    DISEASES. 


These  endothelial  cells  were  markedly  enlarged  and  projected  into  the  lumina  of  the 
lymphatics.  The  stroma-cells  in  the  vicinity  were  very  large  (Fig.  195),  but  the 
majority  of  them  contained  no  nuclei  and  looked  more  like  cells  undergoing  degenera- 
tion. This  case,  apart  from  dilatation  of  the  lymphatics,  bore  a  striking  resemblance 
to  those  reported  by  Virchow  and  Kaufmann.  Abstracts  of  Kaufmann's  and  von 
Winckel's  cases  are  appended. 

v  A  Congenital  Umbilical  Tumor.*  —  On  the  second  day  after 
birth  Lissner  saw  the  child.  The  mother  was  forty-eight  years  of  age,  strong,  and 
well  nourished.  The  patient  was  the  twelfth  child.  The  labor  had  been  easy, 
and  the  umbilical  tumor  had  caused  no  hindrance.  At  first  it  was  small,  but 
by  the  end  of  twenty-four  hours  had  grown  markedly.  When  seen,  it  was  the  size 
of  an  apple,  reddish  in  color.  The  skin  of  the  abdomen  extended  up  for  some 
distance  on  the  sides  of  the  tumor.  The  remaining  portion  of  the  tumor  was 
covered  over  with  amnion,  which  was  continued  upon  the  umbilical  cord.     The 

tumor  was  firm  in  consistence, 
and  on  pressure  could  not  be 
rendered  smaller.  After  six 
days  it  had  grown  a  good  deal 
and  there  had  been  bleeding 
from    it,     which     had     been 


Fig.  191. — Telangiectatic  Myxosarcoma  of  the  Umbilicus. 
(After  Kaufmann.) 
This  is  from  the  specimen  after  it  had  been  hardened  in  alcohol. 
Below  and  to  the  left  one  sees  where  the  tumor  has  been  amputated 
from  the  umbilicus.  To  the  right  is  the  attachment  of  the  cord. 
Here  the  tumor  was  partly  covered  with  amnion. 


Fig.  192. — Appearance  op  the  Umbilicus 
After  Removal  of  the  Tumor  shows 
in  Fig.  191.      (After  Kaufmann.) 
a,  The  umbilical  vein;   b,  cross-section 

of  the  umbilical  artery;  c,  cross-sections  of 

other  arteries. 


checked  by  the  use  of  styptics.  Under  chloroform  narcosis  three  needles  were 
passed  through  the  base  of  the  tumor  and  a  bichlorid  silk  thread  was  tied  around 
it.  The  tumor  was  then  cut  away,  and  the  wound  dressed  antiseptically.  Six  days 
later  the  remnant  of  the  tumor  was  recognized  as  a  thick,  brown,  hard,  dry,  mummi- 
fied crust,  which  came  away  readily.     Healing  took  place  rapidly. 

The  tumor  (Fig.  191)  was  firm  in  consistence,  almost  round,  16  cm.  in  circum- 
ference, and  reached  a  height  of  6  cm.  At  its  base,  where  it  passed  to  the  umbilical 
ring,  were  seen  cross-sections  of  the  umbilical  arteries  and  of  the  umbilical  vein. 
The  latter  contained  a  red  thrombus.  In  addition  there  were  cross-sections  of 
other  blood-vessels  (Fig.  192). 

Xear  the  surface  the  tumor  is  everywhere  dense  and  fibrous.  In  the  middle 
portion  it  is  of  a  myxomatous  character,  and  in  this  myxomatous  tissue  are  numer- 
ous blood-vessels,  some  of  which  present  a  cavernous  appearance  (Fig.   193). 

*  Kaufmann:  Ueber  eine  Geschwulstbildung  des  Xabelstrangs.  Virchows  Arch.,  1890, 
cxxi,  513. 


SARCOMA    OF    THE    UMBILICUS.  451 

Beneath  the  surface  epithelium  the  cells  are  partly  round,  but  to  a  great  extent 
spindle-shaped.  These  spindle-cells  are  narrow  and  often  long,  resembling  muscle- 
fibers,  but  the  nuclei  are  more  delicate.  From  the  picture  Kaufmann  concludes 
that  it  is  a  spindle-cell  sarcoma.  As  one  nears  the  center  of  the  tumor  the  spindle- 
cells  become  more  sparse  and  we  have  a  picture  of  myxomatous  tissue.     It  is  in  the 


Ste  it"?  '••• 


"V 


*seSE 


M      •  ---'v.     -?    ■■,/- ?:j*  .      ?xgE£ji&    ■■..-■; 


'    • 


J         1      ? 

*/                ;    ''        /''  ^ 

■r  -- 

>   v< 

Fig.   193. — Myxosarcoma  of  the  Umbilicus.      (After  Kaufmann.) 
This  is  a  low-power  picture  of  Fig.  191.     At  a,  where  we  should  have  the  epithelial  covering,  it  has  been  rubbed  off. 
Beneath  this  the  tumor  is  dense  and  consists  of  spindle-cells.     The  central  portion,  d,  is  composed  of  mucoid-like  tissue 
containing  large  arterial  sinuses. 

myxomatous  portion  of  the  tumor  that  the  blood-vessels  have  increased  in  size  and 
that  a  cavernous  appearance  is  noted.  Some  of  the  blood-vessels  show  many 
branchings — some  narrow,  others  wide.  A  few  of  the  vessels  are  still  filled  with 
blood.  The  cavernous  appearance  is  due  to  dilated  arteries.  Kaufmann  designates 
the  tumor  as  a  myxosarcoma  telangiectodes,  and  speaks  of  its  resemblance  to  the 
case  reported  by  Virchow. 


452 


THE    UMBILICUS    AXD    ITS    DISEASES. 


A  Congenital  Solid  Tumor  of  the  Umbilical  Portion 
of  the  Cord.  —  On  December  16,  1893,  von  Winckel*  saw  a  female  child,  49 
cm.  long  and  weighing  2500  grams.     At  the  margin  of  the  umbilical  cord,  immedi- 


Fig.  194. — Telangiectatic  Myxosarcoma  Projecting  From  the  Right  Side  of  the  Umbilicus.     (After  v.  Winckel.) 
a,  The  cord;   6,  the  margin  of  the  amnion  over  it;   c,  the  telangiectatic  myxosarcoma. 


ately  after  labor,  a  tumor  had  been  noted  (Fig.  194).     This  was  firm  in  consistence, 

bright  red  in  color,  and  had  here  and  there  a  bluish,  translucent  surface.     Near  the 

free  end  were  two  fine  threads 
with  small  bodies  the  size  of  lin- 
seeds on  their  surfaces.  The  en- 
tire tumor  was  4  cm.  long,  at  its 
base,  2.8  cm.  thick,  and  near  the 
end,  1.6  cm.  in  diameter.  The 
tumor  was  removed  with  the 
cautery,  and  the  peritoneum 
opened  for  a  breadth  of  from  2 
to  5  mm.,  a  small  quantity  of 
serous  fluid  escaping.  The  oper- 
ation did  not  last  over  fifteen 
seconds.  A  compression  band 
was  applied,  and  the  child 
made  a  satisfactory  recovery. 
Fourteen  daj^s  later,  however, 
she  died  suddenly  of  pneu- 
monia. 
The  outer  surface  of  the  tumor  was  covered  with  what  appeared  to  be  hyaline 

membrane,  which  contained  connective-tissue  nuclei  in  large  or  small  numbers. 

Beneath  the  surface  there  was  a  net-like  arrangement  of  threads  consisting  of 

*  von  Winckel:  Ueber  angeborene  solide  GeschwiiLste  des  (perennirenden)  Theiles  der  Nabel- 
schnur.     Sammlung  klin.  Yortrage,  n.  F.  No.  140.     (Gyn.  Nr.  53.) 


Fig.  195. — A  Telangiectatic  Myxosarcoma.     (After  v.  Winckel.) 
The  section  is  from  the  tumor  seen  in  Fig.  194.     It  consists  of 
very  large,  well-defined  cells,     r,  r,  Giant-cells.     Here  and   there 
between  the  cells  are  a  few  leukocytes. 


SARCOMA    OF    THE    UMBILICUS.  453 

connective-tissue  nuclei  and  leukocytes.  In  the  superficial  layers  of  the  tumor 
there  was  an  abundance  of  large  blood-vessels.  In  addition  there  were  lymph- 
vessels  showing  a  definite  endothelial  lining;.  These  contained  fibrin  threads  and 
leukocytes.  The  endothelium  of  the  lymphatics  appeared  to  be  proliferating. 
The  endothelial  cells  were  markedly  enlarged  and  projected  into  the  lumen;  here 
and  there  they  contained  mitotic  figures.  In  the  vicinity  of  these  lymph-spaces, 
in  the  connective  tissue,  spindle-shaped  cells  were  seen,  between  which  there 
appeared  to  be  some  fluid.  There  were  also  large  epithelioid  cells  in  the  stroma 
(Fig.  195).  These  stained  with  hematoxylin-eosin  a  diffuse  violet.  The  majority 
contained  no  nuclei  and  resembled  degenerated  tissue-cells. 

In  the  pedicle  of  the  tumor  a  similar  structure  was  noted.  The  large,  deeply 
tinged  cells,  however,  were  lacking.  The  blood-vessels  were  abundant.  Von 
Winckel  said  that,  from  the  description  of  his  case,  there  was  no  doubt  that  he  was 
dealing  with  a  telangiectatic  myxosarcoma  similar  to  those  reported  by  Virchow 
and  Kaufmann. 

From  a  careful  study  of  these  cases  it  would  appear  that  they  bear  a  marked 
resemblance  to  those  considered  under  angiomata  of  the  umbilicus,  and  that,  in  all 
probability,  they  should  be  included  in  that  class.  They  do  not  seem  to  be  malig- 
nant. 

SPINDLE-CELL  SARCOMA  OF  THE  UMBILICUS. 

Only  a  few  instances  have  been  recorded,  and,  as  pointed  out  by  Nicaise, 
Perniee,  and  others,  even  in  such  cases  careful  histologic  reports  are  usually  lacking. 
Spindle-cell  sarcoma  of  the  umbilicus  would  appear  to  be  the  most  common  variety, 
and  the  growth  has  been  designated  as  a  spindle-cell  sarcoma,  a  fibrosarcoma,  a 
myxosarcoma,  or  a  sarcoma  fibrocellulare. 

Firm  connective-tissue  growths  of  the  umbilicus  are  relatively  rare.  They  may 
occur  in  the  young,  middle-aged,  or  old.  They  usually  are  oval  or  round,  and  may 
slowly  or  rapidly  reach  the  size  of  a  fist  or  an  orange.  As  a  rule,  they  have  an 
intact  skin  covering.  This  may  be  normal,  have  large  veins  coursing  over  its 
surface,  or  the  skin  may  show  a  purple  discoloration.  Occasionally,  as  a  result  of 
irritation,  the  surface  of  the  tumor  may  be  slightly  ulcerated.  The  tumor  may  be 
sessile  or  somewhat  pedunculated. 

Clinically,  it  is  almost  impossible  to  determine  whether  such  a  growth  is  a 
fibroma  or  a  spindle-cell  sarcoma  unless  metastases  occur;  and,  even  if  a  nodule 
develops  in  the  abdominal  wall,  several  months  or  a  year  or  more  after  the  tumor 
has  been  removed,  there  is  still  the  possibility  that  this  second  nodule  may  be  a 
fibroma. 

On  section,  most  of  these  tumors  have  a  fibrous  appearance,  few  of  them  pre- 
senting the  homogeneous,  pork-like  surface  so  characteristic  of  sarcoma.  If,  on 
histologic  examination,  the  cells  contain  large,  irregular  nuclei  with  deeply  staining 
chromatin,  or  if  nuclear  figures  are  abundantly  distributed  throughout  the  tumor, 
the  diagnosis  of  sarcoma  is  clear.  If,  on  the  other  hand,  only  quiescent  spindle- 
cells  are  in  evidence,  it  is  absolutely  impossible  to  make  the  diagnosis  from  the  histo- 
logic findings,  and  the  surgeon  remains  in  the  dark  as  to  the  exact  character  of  the 
tumor,  unless  its  malignancy  is  clearly  shown  by  the  later  development  of  metastases. 

Where  the  sarcoma  of  the  umbilicus  is  secondary,  the  growth  may  tend  to 
spread  out  into  the  abdominal  wall  and  wall  not  be  so  prominent  and  well  defined. 


454  THE    UMBILICUS    AND    ITS    DISEASES. 

Cases  Reported  as  Instances  of  Spindle-cell  Sarcoma  of  the  Umbilicus. 

Some  of  these  tumors  were  clearly  sarcomatous;  others  in  all  probability  were 
fibromata.  The  reader  can  draw  his  own  conclusions  as  to  the  proper  diagnosis  in 
each  case.  Those  cases  that  were  clearly  instances  of  fibroma,  although  previously 
classified  as  sarcoma,  are  included  under  fibromata,  while  quite  a  number  in  which 
not  even  a  probable  diagnosis  could  be  made  have  been  entirely  omitted. 

Spindle-cell  Sarcoma  of  the  Umbilicus.*  —  This  tumor 
was  removed  by  Wehsarg  from  the  umbilical  region  of  a  poorly  nourished  girl  aged 
fourteen.  The  tumor  had  grown  slowly  until  three  or  four  years  before,  when  it 
had  suddenly  become  painful  and  rapidly  grown  to  the  size  of  a  fist.  At  operation 
it  was  round  and  the  size  of  an  orange,  smooth,  smaller  at  its  base,  and  slightly 
pendulous,  the  umbilicus  being  pushed  down.  The  skin  over  the  tumor  was  very 
thin,  bluish  red  in  color,  and  there  were  numerous  dilated  veins.  The  lower  part  of 
the  tumor  showed  several  excoriated  ulcerated  plaques  covered  with  clots  and  pus. 
The  tumor  was  removed.  It  lay  on  the  superficial  fascia  of  the  abdominal  wall. 
On  section  it  was  yellow,  homogeneous,  and  resembled  pork,  with  here  and  there 
darker  places  surrounded  by  vessels.  Microscopically  it  proved  to  be  a  spindle- 
cell  growth. 

Possible  Sarcoma  of  the  Umbilicus.  —  Villarf  describes  the 
case  of  a  woman  aged  forty-six  who  entered  the  service  of  Professor  Guyon,  Sep- 
tember 17,  1886.  About  December,  1885,  she  had  noticed  that  her  corsets  pro- 
duced pain  in  the  umbilical  region,  and  on  examination  had  found  a  small,  reddish 
tumor  the  size  of  the  head  of  a  pin  in  the  umbilical  depression.  This  tumor  grew 
slowly.  In  May,  1886,  the  patient  presented  herself  at  the  hospital  for  examina- 
tion. In  August,  after  she  had  been  using  iodin  without  any  results,  she  again 
came  to  the  hospital.  Examination  at  this  time  showed  that,  at  the  umbilical 
depression,  was  a  tumor  the  size  of  a  small  bird's  egg,  but  different  in  form.  It  was 
conic,  with  its  base  continuous  with  the  umbilical  cicatrix.  It  was  slightly  peduncu- 
lated, firm  in  consistence,  but  elastic  and  reddish  in  color.  At  its  top  was  a  blackish 
point  2  mm.  in  diameter.  There  was  no  discharge  from  the  tumor.  Two  or  three 
days  later  the  blackish  point  ruptured  and  there  was  an  escape  of  dark  blood.  No 
glandular  enlargement  was  detected.  The  tumor  was  removed.  The  tumor  in 
question  was  a  little  less  firm  than  a  fibroma.  On  section  a  capsule  was  found  sur- 
rounding the  central  mass.  The  tumor  was  whitish  gray  and  had  numerous  dark 
spots  no  larger  than  the  head  of  a  pin  scattered  throughout  it. 

Histologic  examination  showed  that  the  capsule  was  formed  of  connective 
tissue.  The  central  portion  of  the  tumor  was  composed  of  sarcomatous  tissue,  the 
cells  being  fusiform.  In  the  center  of  the  tumor  there  were  cavities  lined  with 
pavement-cells.  These  cavities  presented  various  forms.  Some  were  round,  others 
were  oval  and  had  anastomosed  with  one  another.  In  the  stroma  between  the 
spaces  were  a  small  number  of  blood-vessels.  The  skin  covering  the  outer  surface 
of  the  tumor  was  exceedingly  thin,  but  presented  the  usual  appearance.  In  the 
center  there  had  been  some  extravasation  of  blood  recognizable  by  deposits  of  pig- 
ment. 

(This  woman  was  forty-six  years  of  age.     Although  the  description  is  not  per- 

*  Leydhecker,  F. :  Zur  Diagnose  der  sarcomatosen  Geschwiilste,  Giessen,  1856. 
t  Villar,  Francis:   Tumeurs  de  l'ombilic.     These  de  Paris,  1886,  obs.  68. 


SARCOMA    OF    THE    UMBILICUS.  455 

fectly  clear,  it  bears  somewhat  the  ear-marks  of  the  ease  reported  by  Mintz — a  case 
that  proved  to  be  an  adenomyoma  of  the  umbilicus  (see  Fig.  174,  p.  381).  It  does 
not  tally  with  our  usual  idea  of  sarcoma. — T.  S.  C] 

A  Case  of  Myxosarcoma  of  the  Umbilicus.  —  Plagge* 
reports  the  case  of  a  man,  twenty-two  years  of  age,  who  in  childhood  had  had  diffi- 
culty in  digestion  and  later  vomiting  and  diarrhea.  In  the  summer  of  1887  he  had 
pain  in  the  stomach  for  the  first  time  and  noticed  a  small  tumor  in  the  umbilicus. 
By  November,  1887,  the  tumor  was  the  size  of  a  hazel-nut.  Four  weeks  later  there 
was  a  nodule  the  size  of  a  pea  below  and  to  the  left,  close  to  the  linea  alba.  The 
patient  was  much  emaciated.  He  died  on  March  14,  1888.  At  autopsy,  at  the 
umbilicus  a  thickening  the  size  of  a  five-mark  piece  was  noted  rising  2  cm.  above 
the  abdominal  level.  Above  and  below,  this  thickening  could  be  followed  5  cm.  in 
each  direction;  the  skin  was  movable  over  it.  On  examination  of  the  abdominal 
cavity  in  the  region  of  the  umbilicus  was  a  nodule,  2  mm.  in  diameter.  In  the  liga- 
ment passing  from  the  umbilicus  was  a  small  nodule.  The  omentum,  diaphragm, 
and  intestines  were  involved.     The  stomach  was  normal. 

Microscopic  examination  showed  that  the  growth  was  a  myxosarcoma. 

[If  this  had  been  a  primary  malignant  growth,  why  had  it  not  broken  clown? 
The  clinical  picture  in  no  way  indicates  a  primary  growth.  The  histologic  appear- 
ance suggests  very  much  a  colloid  carcinoma  of  the  intestine  with  a  secondary 
growth  at  the  umbilicus. — T.  S.  C] 

Sarcoma  at  the  Umbilicus,  f  —  An  East  Indian  male,  aged  twenty- 
four  years,  was  admitted  on  June  2, 1889.  Several  weeks  before,  April  5th,  he  had  ex- 
posed himself  to  the  night  air  after  returning  from  a  party.  The  next  morning  he  felt 
pain  in  and  around  the  umbilicus.  Two  weeks  later  a  small,  hard  swelling  was  de- 
tected in  the  navel,  and  in  a  few  days  an  unpleasant  sensation  in  this  region  caused 
vomiting.  The  swelling  was  considered  inflammatory  in  origin,  and  local  applica- 
tions were  made.  On  examination  a  subcutaneous  growth  the  size  of  a  hen's  egg 
was  found  situated  exactly  at  the  umbilicus.  The  skin  covering  it  was  deep  purple 
and  firmly  adherent.  The  growth  was  apparently  deeply  attached  by  a  pedicle 
fixed  to  the  right  side  of  the  umbilicus.  A  few  hard  bosses  were  noted  over  the 
surface  of  the  tumor,  and  a  nodule  the  size  of  a  hazel-nut,  detected  on  the  right 
abdominal  wall,  was  apparently  connected  with  the  tumor.  This  nodule  was  situ- 
ated about  three  and  a  half  inches  from  the  umbilicus.  The  secondary  growth  had 
only  recently  been  noted.     Both  tumors  were  tender  to  the  touch. 

The  main  growth  and  the  secondary  nodule  were  removed,  but  the  abdomen  was 
not  opened.  The  patient  did  not  improve,  but  became  profoundly  cachectic. 
About  a  month  after  operation  a  small,  freely  movable  nodule  was  felt  in  the  sub- 
cutaneous connective  tissue,  about  an  inch  from  the  abdominal  incision  below  the 
umbilicus.  Soon  after,  another  was  noted  in  the  left  rectus,  close  to  the  cartilage  of 
the  ribs.  This  increased  rapidly;  there  was  great  nausea  and  occasional  vomiting, 
suggesting  dissemination  in  the  diaphragm.  [Microscopic  examination  showed  that 
the  umbilical  growth  was  a  fibrosarcoma.  The  abdomen  was  not  opened.  The 
secondary  growth  proved  the  malignancy  of  the  condition,  and  the  vomiting  and  loss 
of  weight  strongly  suggested  a  primary  abdominal  growth  with  secondarj^  manifesta- 
tions at  the  umbilicus.] 

*  Plagge,  Heinrich:    Ein  Fall  von  Myxosarconi  des  Nabels.     Inaug.  Diss..  Freiburg,  1889. 
t  O'Brien,  Surgeon- Maj or:   Indian  Med.  Gaz.,  1889,  xxiv,  215.. 


456  THE    UMBILICUS    AND    ITS    DISEASES. 

A  Supposed  Sarcoma  of  the  Umbilicus.  —  Neveu*  reported 
an  unpublished  case  of  Monnier's.  The  patient  was  a  woman  fifty  years  old.  She 
had  a  uterine  growth  which  extended  to  the  umbilicus.  The  curet  showed  sarcoma 
fusocellulare.  Implicating  the  umbilicus  was  a  mass  the  size  of  a  hazelnut.  No 
microscopic  examination  of  the  umbilical  growth  was  made. 

[It  is  often  very  difficult,  when  examining  a  submucous  myoma,  to  determine 
whether  it  is  really  a  spindle-cell  sarcoma  or  a  simple  myoma.  Without  an  exami- 
nation of  the  umbilical  nodule  we  should  hesitate  to  accept  this  as  representing  a 
nodule  secondary  to  the  growth  in  the  uterus. — T.  S.  C] 

Sarcoma  of  the  Umbilicus.  —  Pernicef  reports  the  cases  of  Blum, 
Bryant,  and  Villar.  None  of  the  descriptions  seem  to  me  to  be  convincing  enough 
to  warrant  the  growths  being  included  as  sarcomata. 

Pernice  then  reports  from  the  Halle  Clinic  the  case  of  R.  Schroeder,  aged  nine- 
teen. As  a  child  she  had  a  small  tumor  at  the  umbilicus.  It  was  not  painful  and 
did  not  grow  until  the  thirteenth  year;  it  was  then  extirpated.  Two  years  later  a 
new  tumor  appeared,  and,  when  she  was  admitted  to  the  hospital,  it  was  the  size  of  a 
baby's  head  and  was  covered  with  intact  umbilical  skin.  The  tumor  shone  through 
the  skin  and  was  hard.  The  inguinal  glands  were  not  enlarged.  The  abdomen  was 
widely  opened  during  removal  of  the  tumor,  and  the  patient  recovered.  About 
three  years  later  she  was  in  good  condition,  but  shortly  afterward  a  return  of  the 
growth  was  noted.  This  tumor  was  the  size  of  a  small  apple  when  the  patient  came 
back  to  the  hospital.     It  was  situated  in  the  upper  angle  of  the  previous  incision. 

No  histologic  examination  was  given.  This  tumor  had  not  yet  been  removed 
when  Pernice  reported  the  case. 

[Pernice  then  goes  on  to  report  several  other  cases,  none  of  which  would  appear 
to  be  an  undoubted  instance  of  sarcoma. 

Although  it  is  quite  possible  that  the  growth  reported  by  Pernice  was  a  sarcoma, 
we  must  remember  that  it  may  equally  well  have  been  a  fibroma.  Where  one 
fibroma  develops,  others  are  prone  to  occur. — T.  S.  C] 

Possibly  a  Sarcoma  of  the  Umbilicus.  —  SourdilleJ  reports 
the  case  of  a  man,  forty-nine  years  of  age,  who  entered  Polaillon's  service  at  the 
Hotel-Dieu  March  25,  1895.  Eighteen  months  before  he  had  noticed  at  the  umbili- 
cus small  tubercles.  These  caused  him  some  pain  and  inconvenience.  On  admis- 
sion, attached  to  the  lower  border  of  the  umbilicus  was  found  a  pedunculated 
cylinclric  tumor,  5  cm.  long  and  12  to  13  mm.  in  diameter.  Its  free  end  was  covered 
with  a  small  crust  over  a  healed  ulceration.  The  skin  covering  it  was  delicate,  thin, 
reddish  in  color.  When  grasped  between  the  fingers,  the  tumor  gave  the  sensation 
of  a  finger  of  a  glove  filled  with  hazelnuts.  The  skin  surrounding  the  tumor  con- 
tained seven  or  eight  pink  tubercles,  about  the  size  of  green-peas.  The  skin  was 
movable  on  the  underlying  aponeurosis.  No  enlargement  of  the  glands  could  be 
made  out.     The  patient's  general  health  was  good.     The  diseased  area  was  removed. 

On  histologic  examination  the  main  tumor  and  the  small  nodules  gave  a  picture 
of  sarcoma  fusocellulare  covered  -with  skin.     The  superficial  half  of  the  skin  seemed 

*  Neveu:  Contribution  a  l'etude  des  tumeurs  malignes  secondares  de  l'ombilic,  Paris, 
1890. 

t  Pernice,  L. :  Die  Xabelgeschwulste,  Halle,  1892. 

+  Sourdille,  Gilbert:  Sarcome  pedicule  de  la  peau  de  l'ombilic.  Bull,  de  la  Soc.  anat.  de 
Paris,  189.5,  lxx,  302. 


SARCOMA    OF   THE    UMBILICUS.  457 

to  be  the  starting-point  of  the  tumors,  which  tended  to  pass  out  and  become  pedun- 
culated. 

[This  growth  may  equally  well  have  been  a  fibroma  with  very  small  nodules. 
The  microscopic  examination  was  not  very  extensive.] 

Primary  Sarcoma  of  the  Umbilicus.  —  Gamier  *  reports  for 
Blanc  the  case  of  an  otherwise  healthy  man  fifty  years  old.  Six  months  previously 
he  had  noticed  a  small,  hard,  painless  tumor  in  the  right  border  of  the  umbilical 
depression.  It  was  independent  of  the  skin,  and  was  the  size  of  a  hazelnut.  The 
patient  had  some  colic,  but  no  constitutional  trouble.  He  thought  that  the  pain  in 
the  pyloric  region  was  due  to  pressure  of  the  growth  on  the  pylorus.  He  had  lost  in 
weight  in  the  last  month. 

On  admission  the  tumor  was  the  size  of  a  mandarin  orange,  round,  and  was  carry- 
ing the  unfolded  umbilicus  on  its  surface.  It  was  hard,  painless,  and  firmly  fixed 
by  the  contraction  of  the  abdominal  muscles.     The  overlying  skin  was  purple. 

At  operation  it  was  found  that  the  tumor  had  developed  in  the  deeper  layers. 
The  underlying  peritoneum  was  perfectly  smooth,  and  the  tumor  was  easily  re- 
moved. Blanc  regarded  it  as  a  great  rarity,  this  being  the  first  instance  observed. 
He  based  his  assumption  that  the  growth  was  primary  on  the  absence  of  functional 
trouble  and  on  the  relative  integrity  of  the  patient's  general  condition. 

[He  does  not  mention  the  examination  of  the  abdominal  cavity  at  the  time  of 
operation,  and  furthermore  does  not  account  for  the  sense  of  discomfort  experienced 
in  the  region  of  the  stomach;  nor  do  we  know  the  final  outcome. — T.  S.  C] 

On  microscopic  examination  the  growth  was  found  to  be  composed  of  myriads  of 
small  cells  separated  from  one  another  by  a  delicate  stroma.  The  cells  in  general 
were  round  or  fusiform  and  had  but  little  protoplasm.  Histologically,  the  growth 
appeared  to  be  malignant  and  was  a  sarcoma.  It  had  developed  from  the  fibrous 
tissue  of  the  abdominal  wall. 


ROUND-CELL  SARCOMA  OF  THE  UMBILICUS. 

The  following  case  represents  the  only  definite  instance  of  round-cell  sarcoma  of 
the  umbilicus  with  which  I  am  familiar.     The  umbilical  growth  was  a  secondary  one. 

Pernicef  reports  a  secondary  sarcoma  of  the  umbilicus  (Case  71,  from  the  Breslau 
Gyn.  Clinic) .  The  patient  was  a  woman  thirty-two  years  of  age.  The  umbilicus 
was  lifted  3  cm.  above  the  surface  of  the  abdomen.  It  had  the  form  of  an  egg-cup, 
was  very  hard,  but  covered  with  normal  skin.  There  was  marked  ascites,  which 
made  palpation  useless.  At  operation  eight  liters  of  hemorrhagic  fluid  were  removed 
and  the  omentum  protruded.  Scattered  over  it  were  tumors  the  size  of  plums. 
The  umbilical  tumor  was  completely  isolated  and  was  removed.  It  was  in  no  way 
connected  with  the  omentum.  The  primary  tumor  could  not  be  discovered.  Micro- 
scopic examination  showed  that  the  tumors  were  large  round-cell  sarcomata. 


MELANOTIC  SARCOMA  OF  THE  UMBILICUS. 
Pernice  draws  attention  to  two  cases — -one  observed  by  Volkmann,  the  other  by 
Olshausen.     Volkmann's  case  occurred  in  a  young  girl  who  had  an  umbilical  tumor 

*  Garnier:   Cancer  [Sarcoma]  primitif  de  l'ombilic.     La  Loire  medicale,  1910,  xxix,  503. 
t  Pernice,  L. :  Op.  cit.,  obs.  71. 


458  THE    UMBILICUS    AXD    ITS    DISEASES. 

not  larger  than  a  cherry.  Notwithstanding  the  wide  removal  of  the  growth,  count- 
less secondary  tumors  were  soon  noted  and  the  girl  died. 

Olshausen's  patient  was  a  woman  twenty-one  years  of  age.  She  had  at  the 
umbilicus  a  melanotic  sarcoma  the  size  of  an  apple.  It  had  been  noted  first  a  year 
and  a  half  before  she  came  for  operation.  The  growth  was  removed,  but  twenty- 
one  months  later  the  patient  died,  with  brain  symptoms  strongly  indicative  of  cere- 
bral metastases. 

Catoir*  also  reports  a  case  of  melanotic  sarcoma  of  the  umbilicus.  The  patient 
was  a  man  sixty-five  years  old.  He  noticed  a  slight,  faintly  blood-tinged  discharge 
from  the  umbilicus.  At  that  time  there  could  be  seen  a  simple  brownish  spot,  with- 
out any  underlying  induration.  Four  months  later  there  was  a  thickening  sur- 
rounding the  umbilicus.  Applications  were  employed,  and  an  attempt  was  made 
to  remove  the  growth  with  the  thermocautery.  Two  months  later  the  tumor  was 
3  cm.  in  diameter.  It  was  raised  and  formed  a  semicircle  with  the  umbilicus  in  the 
ceEter.     The  tumor  was  removed.     Xo  note  is  given  as  to  the  prognosis. 

^Microscopic  examination  corresponded  with  the  clinical  diagnosis  of  melanotic 
sarcoma.     Xo  other  primary  source  of  the  growth  could  be  found. 

[Despite  the  probability  of  the  correctness  of  the  diagnosis,  in  the  absence  of  an 
abdominal  exploration  it  is  impossible  to  feel  sure  that  the  growth  was  primary. 
— T.  S.  C] 

*  Catoir,  S.:  Sarcome  melanique  de  la  region  ombilicale  chez  un  homme  de  65  ans.  Jour. 
d.  sci.  med.  de  Lille,  1899,  xxii,  36. 


LITERATURE  CONSULTED  ON  SARCOMA  OF  THE  UMBILICUS. 
Aveling:    Brit.  Gyn.  Jour.,  1886-87,  ii,  56;    187. 

Berard,  P.  H.:   Fistules  urinaires.     Diet,  de  med.,  Paris,  1840,  xxii,  64. 
Blum,  A.:    Tumeurs  de  l'ombihc  ehez  l'adulte.     Arch.  gen.  de  med.,  Paris,  1876,  6.  ser.,  xxviii, 

151. 
Catoir,  S.:   Sarcome  melanique  de  la  region  ombilicale  chez  un  homme  de  65  ans.     Join,  des  sci. 

med.  de  Lille,  1899,  xxii,  36. 
Dannenberg,   O.:    Zur  Casuistik  der  Xabeltumoren  insbesondere  des    Carcinoma    umbihcale. 

Inaug.  Diss.,  Wlirzburg,  1886. 
Demarquay:  Cancer  de  l'ombihc.     Bull,  de  la  Soc.  de  chir..  1870-71,  2.  ser.,  xi,  209. 
Forgue  et  Riche:  Montpellier  med.,  1907,  xxiv,  145. 

Gamier:  Cancer  [Sarcoma]  primitif  de  l'ombihc.     La  Loire  med.,  1910,  xxix,  503. 
Kaufmann,  E.:  Leber  eine  Geschwulstbildung  des  Xabelstrangs.    Virchows  Arch.,  1890,  exxi,  513. 
Leydhecker.  F.:  Zur  Diagnose  der  sarcomatosen  Geschwlilste,  Giessen,  1S56. 
Xeveu,  X.:  Contribution  a  l'etude  des  tumeurs  malignes  seeondaires  de  l'ombihc,  Paris,  1S90,  No. 

50. 
Nicaise:  Fibro-papilloma  de  la  cicatrice  ombilicale.     Rev.  de  chir.,  Paris,  1883,  hi,  29. 
O'Brien,  Surgeon-Major:   Sarcoma  at  the  Umbilicus.     Indian  Med.  Gaz.,  1889.  xxiv,  215. 
Pernice,  L. :    Die  XabelgeschwuLste,  Halle,  1892. 

Plagge,  H.:  Ein  Fall  von  Myxosarcom  des  Nabels.     Inaug.  Diss.,  Freiburg,  1889. 
Quenu  et  Longuet:  Du  cancer  secondaire  de  l'ombilic.     Rev.  de  chir.,  1896,  xvi,  97. 
Sourdille,  G.:    Sarcome  pedicule  de  la  peau  de  l'ombihc.     Bull,  de  la  Soc.  anat.  de  Paris,  1895, 

Lxx,  302. 
Tillmanns.  H.:   Deutsche  Zeitschr.  f.  Chir.,  1882-83,  xviii,  161. 
Yillar,  Francis :    Tumeurs  de  l'ombihc.     These  de  Paris,  1886. 
Yirchow,  R.:   Virchows  Arch.,  1864,  xxxi,  128. 
von  Winckel,  F.:   Ueber  angeborene  solide  Geschwiilste  des  (perennirenden)  Theiles  der  Xabel- 

schnur.     Sammlung  klin.  Vortrage,  n.  F.  Xo.  140.    (Gyn.  Nr.  53.) 


CHAPTER  XXVII. 
UMBILICAL  HERNIA. 

Hernia  into  the  umbilical  cord. 

Amniotic  hernia. 

Congenital  nipping  off  of  an  umbilical  hernial  protrusion. 

Small  umbilical  hernia  at  birth. 

Serous  umbilical  hernia;  report  of  cases. 

Serous  umbilical  hernia  in  children. 

Escape  of  serous  fluid  from  the  umbilicus  in  a  case  of  tuberculous  peritonitis. 

Serous  umbilical  hernia  associated  with  an  ovarian  cyst. 

A  serous  umbilical  hernia  associated  with  a  large  cystic  myoma  and  marked  abdominal  ascites. 

Umbilical  hernia  in  the  adult;  radical  cure  in  a  patient  weighing  464  pounds. 

Cysts  of  the  umbilicus. 

Umbilical  hernia  has  been  so  thoroughly  considered  in  the  texi>-books  on 
surgery  that  I  shall  here  confine  myself  to  a  very  brief  description  of  the  various 
forms  of  hernia  in  this  region. 

1.  Hernia  into  the  umbilical  cord. 

2.  Amniotic  hernia. 

3.  Congenital  nipping-off  of  a  hernial  protrusion. 

4.  A  small  umbilical  hernia  at  birth. 

5.  Serous  umbilical  hernia. 

6.  Umbilical  hernia  in  the  adult. 

7.  Cysts  of  the  umbilicus. 

HERNIA  INTO  THE  UMBILICAL  CORD. 

A  reference  to  the  chapter  on  Embryology  (Fig.  8,  p.  8;  Fig.  10,  p.  10;  Fig. 
11,  p.  11,  and  Fig.  12,  p.  12),  will  show  that  in  the  early  months  of  fetal  life  the  greater 
portion  of  the  small  intestine  lies  in  the  umbilical  cord.  This  extra-abdominal 
cavity  is  called  the  exoccelomic  cavity.  The  intestine  gradually  withdraws  into 
the  abdomen,  and  the  cavity  in  the  cord  becomes  obliterated. 

In  rare  instances,  however,  this  opening  does  not  close.  In  such  cases  at  birth 
there  is  a  cystic  swelling  at  the  fetal  end  of  the  cord.  The  cyst-walls  are  very  thin, 
consisting,  for  the  most  part,  of  the  amnion  and  of  peritoneum;  consequently,  the 
intestinal  loops  within  the  sac  are  readily  visible. 

I  shall  refer  to  only  three  cases  of  this  character — one  mentioned  by  Sheen,  one 
by  D'Arcy  Power,  and  the  third  reported  in  detail  by  Reed. 

Sheen*  mentions  the  case  of  a  patient  seen  by  Hope  at  Queen  Charlotte's  Hos- 
pital. At  birth  there  was  a  hernial  protrusion  into  the  cord.  It  formed  a  mass  the 
size  of  a  hen's  egg.  The  neck  of  the  sac  was  covered  with  skin,  and  the  fundus 
with  the  covering  of  the  cord.     The  umbilical  vessels  were  spread  out  over  the  right 

*  Sheen,  William:  Some  Surgical  Aspects  of  Meckel's  Diverticulum.  Bristol  Medico- 
Chirurg.  Jour.,  1901,  xix,  310. 

459 


460 


THE    UMBILICUS    AND    ITS    DISEASES. 


side  of  the  sac.  The  sac  contained  large  and  small  intestine.  The  small  bowel 
was  adherent  to  the  sac,  but  was  separated  without  difficulty.  What  appeared  to 
be  the  vermiform  appendix  was  so  intimately  fused  with  the  tissues  of  the  umbilical 
cord  that  it  had  to  be  ligated  and  cut  off.     The  child  recovered. 

D'Arcy  Power's*  patient  was  a  full-term  boy.  At  the  fetal  end  of  the  umbilical 
cord  was  a  transparent  sac  containing  several  coils  of  small  intestine  (Fig.  196). 
Taxis  was  employed,  but  it  was  found  impossible  to  push  the  bowel  back  into  the 
abdomen.  The  sac  was  opened,  and  it  was  also  necessary  to  cut  the  umbilical  ring. 
About  one  foot  of  small  intestine  lay  in  the  sac.     After  the  bowel  had  been  returned 


I      it 


o  o 


Umb. 


1^-Cyst 


Fig.  196. — A  Case  of  Congenital  Umbilical  Hernia.  (D'Arcy  Power.) 
The  labor  was  quite  normal.  Situated  in  the  cord  near  the  abdomen  was  a  transparent  sac  containing  several 
coils  of  small  intestine.  The  cord  was  ligated  and  divided  and  an  ineffectual  attempt  was  made  to  replace  the  bowel 
through  the  umbilical  opening.  After  the  application  of  gentle  taxis  for  ten  minutes  the  umbilical  ring  was  enlarged 
and  a  foot  of  small  intestine  was  then  with  some  difficulty  returned  into  the  peritoneal  sac.  The  edges  of  the  ring  were 
subsequently  brought  together  with  silver  wire.  The  child  died  of  peritonitis  three  days  later.  The  tumor  appeared 
to  be  formed  of  a  dilatation  of  the  covering  of  the  cord,  which  was  fusiform  in  shape  and  had  the  main  constituents  of 
the  abdominal  cord  running  as  a  band  along  its  lower  border.  The  wall  of  the  sac  consisted  of  a  thin,  soft  membrane 
which  was  so  transparent  that  the  coils  of  intestine  could  be  seen  through  it.  At  the  apex  of  the  tumor  the  cord  reap- 
peared and  had  on  its  under  surface  a  cyst  containing  viscid  fluid. 


into  the  abdomen  the  hernial  ring  was  closed.  The  child  died  of  peritonitis  on  the 
third  day. 

Powers  said  that  Scarpa  and  Sir  William  Lawrence,  in  their  classic  treatises 
on  rupture,  have  given  a  complete  account  of  this  variety  of  hernia. 

One  of  the  most  remarkable  cases  of  this  character  on  record  is  that  furnished 
by  Edward  N.  Reed,f  of  Clifton,  Ariz.  The  prompt  and  efficient  manner  in  which 
Reed  treated  his  case  shows  how  much  can  occasionally  be  accomplished  even  when 
the  outlook  is  most  unfavorable. 

*  Power,  D'Arcy:  A  Case  of  Congenital  Umbilical  Hernia.  Trans.  Path.  Soc.  London,  1888, 
xxxix,  108. 

t  Reed,  Edward  X.:  Infant  Disemboweled  at  Birth — Appendectomy  Successful.  Jour. 
Amer.  Med.  Assoc,  July  19,  1913,  199. 


UMBILICAL   HERNIA.  461 


Reed  says: 


"I  was  called  to  attend  Senora  Y.  A.,  a  Mexican  woman,  in  confinement,  March 
14th.  I  found  that  the  head  of  the  infant  was  already  free,  and  with  the  next  pain, 
a  moment  later,  the  trunk  was  expelled.  I  was  astonished  at  finding  that  the  whole 
intestine,  both  small  and  large,  was  outside  the  abdominal  cavity.  Examination 
showed  that  the  bowels  had  passed  along  inside  the  cord  for  about  two  inches,  at 
which  point  the  walls  of  the  cord  had  ruptured,  allowing  the  bowels  to  escape  later- 
ally. 

"No  preparations  for  the  confinement  had  been  made;  the  bed  was  filthily 
dirty,  and  the  mass  of  intestines  was  thickly  sprinkled  with  bits  of  straw,  feathers, 
crumbs  of  food,  and  fecal  matter  from  the  mother. 

"I  had  left  the  bedside  of  a  woman  just  about  to  be  delivered  in  order  to  respond 
to  this  call.  I  hurriedly  ligated  the  cord,  delivered  the  placenta,  and  wrapping  the 
baby  in  the  cleanest  thing  I  could  find,  returned  to  the  patient  I  had  left. 

"Finishing  this  case  I  called  my  colleague,  Dr.  T.  B.  Smith,  and  we  went  to- 
gether to  see  the  disemboweled  infant  and  took  it  at  once  to  the  Arizona  Copper 
Company's  Hospital.  It  was  placed  on  the  operating  table  two  hours  after  birth. 
By  this  time  the  bowels  were  matted  together  with  fibrinous  adhesions,  which 
included  many  of  the  particles  of  debris  mentioned  above.  They  were  cleansed 
gently  with  sponges  and  warm  salt  solution,  but  this  cleansing  was  not  very  thor- 
ough, of  course.  The  appendix,  three-fourths  of  an  inch  long,  seemed  to  be  con- 
tused and  swollen,  and  a  catgut  ligature  was  thrown  around  its  base  and  it  was  then 
removed.  The  umbilical  opening  admitted  the  tips  of  two  fingers.  It  was  enlarged 
for  half  an  inch  upward  and  downward,  and  the  cord-bearing  edges  were  trimmed  off. 
The  intestines  were  then  replaced,  and  a  hurried  closure  was  made  with  one  layer 
of  buried  catgut  and  one  of  silkworm-gut. 

"The  child  made  an  uneventful  recovery,  save  for  one  small  stitch-abscess,  and 
is  at  this  date  well  and  growing  normally." 

In  cases  of  this  character  the  wisest  plan  is  to  do  a  radical  operation  at  once. 
If  no  operation  be  performed,  the  cord  must  be  ligated  at  a  point  distal  to  the  hernial 
sac,  but  even  if  the  intestine  can  be  easily  replaced,  the  thin-walled  sac  still  persists, 
and,  as  its  walls  consist  merely  of  amnion  and  peritoneum,  they  are  liable  to  tear 
and  there  will  then  be  great  danger  of  peritonitis. 

AMNIOTIC  HERNIA. 

In  1881  Nicaise*  referred  to  the  amniotic  umbilicus.  He  said  that,  according 
to  Widerhofer,  it  is  characterized  by  an  absence  of  skin  around  the  umbilicus,  the 
defect  being  replaced  by  amnion  which  is  reflected  upon  the  abdomen  from  the  cord. 
In  such  cases  the  surrounding  abdominal  wall  is  generally  intact.  The  amniotic 
umbilicus  does  not  usually  interfere  with  the  health  of  the  child.  In  the  case  men- 
tioned by  Nicaise  the  amniotic  disc  was  gradually  replaced  by  scar  tissue  and  the 
umbilicus  completely  closed. 

R,unge,f  in  1893,  when  discussing  this  subject,  said  that  in  rare  instances  there 
is  a  preponderance  of  amnion  and  a  lack  of  skin  at  the  umbilicus,  and  that  this 
condition  is  spoken  of  as  an  amniotic  umbilicus. 

Where  an  amniotic  umbilicus  exists,  the  intra-abdominal  pressure  naturally 
tends  to  produce  a  hernial  protrusion  at  the  navel,  particularly  if  the  abdominal 
skin  and  underlying  muscular  walls  are  lacking  over  a  wide  area. 

*  Nicaise:    Ombilic,  Diet,  encyclopedique  des  sciences  medicales.    Paris,  1881,  2.  ser.,  xv,  140. 
f  Runge,  M. :    Die  Wundinfectionskrankheiten  der  Neugeborenen.     Die  Krankheiten  der 
ersten  Lebenstage,  Stuttgart,  1893,  2.  Aufl.,  56. 


462 


THE    UMBILICUS    AND    ITS    DISEASES. 


Stewart,*  in  1905,  reported  the  case  of  a  well-developed  male  child  with  a  hernia 
of  the  cord  the  size  of  a  ver}*-  large  apple.  The  cord  dropped  off  at  the  usual  time, 
leaving  the  sac  exposed.  The  child  thrived  well.  Stewart  advised  non-inter- 
ference, but  the  parents  were  particularly  anxious  that  something  should  be  clone. 
Consequently  a  plastic  operation  was  attempted.  The  sac  contained  a  portion  of 
the  intestine  and  the  whole  of  the  liver  so  firmly  adherent  to  the  apex  of  the  sac  that 
its  separation  was  impossible. 

In  1903  Dr.  S.  E.  Sanderson,  f  of  Detroit,  saw  a  new-born  babe  in  whom  the 
anterior  abdominal  walls  had  failed  to  develop.  The  entire  abdominal  contents 
were  visible  through  a  thin,  transparent  covering.  The  covering,  being  distended, 
allowed  the  abdominal  organs  to  press  forward,  forming  a  sort  of  "total  hernia," 


Fig.   197. — An  Amniotic  Hernia.     (Photograph  of  Dr.  H.  Wellington  Yates'  case.) 
The  photograph  is  of  a  new-born  eight-month  child  with  a  large  hernial  protrusion  occupying  the  greater  part  of 
the  anterior  abdominal  wall.     The  walls  of  the  hernia  were  composed  of  a  very  thin  membrane,  which  was  almost 
transparent  and  which  appeared  to  consist  of  amnion  and  peritoneum.     The  skin  of  the  abdominal  wall  extended  up 
the  sides  of  the  sac  for  a  very  short  distance.     The  sac  contained  the  greater  part  of  the  bowel. 


while  the  partly  developed  abdominal  wall,  composed  of  skin,  muscle,  and  peri- 
toneum, was  retracted. 

When  Sanderson  first  saw  the  child  it  was  one  day  old,  was  strong,  in  good  con- 
dition, and  seemed  to  be  unaffected  by  the  physical  defect.  It  nursed  and  cried, 
as  do  other  new-born  babes.  The  thin  abdominal  covering  had,  however,  begun  to 
dry,  and  the  intra-abdominal  pressure  had  already  produced  a  marked  protrusion. 
Dr.  Sanderson  felt  that  the  opportune  time  for  repairing  the  defect  was  past,  but 
as  a  last  resort  he  advised  operation.  This  was  performed  at  the  Grace  Hospital. 
Sanderson,  after  resecting  half  of  the  liver,  was  able  to  bring  the  muscles  and  skin 
together.     The  child  stood  the  operation  well,  but  died  twenty-four  hours  later. 

As  pointed  out  by  Sanderson,  the  time  to  operate  is  immediately  after  birth, 

*  Stewart,  G.  C. :  Hernia  of  the  Umbilical  Cord.     Brit.  Med.  Jour.,  1905,  i,  247. 
f  Personal  communication. 


UMBILICAL    HERNIA.  463 

before  there  is  any  drying  out  of  the  thin  membranous  covering  of  the  abdominal 
wall,  and  before  the  hernial  protrusion  has  been  increased  in  size  by  the  accumula- 
tion of  fluid  in  the  stomach.  As  mentioned  above,  Sanderson  was  not  called  to  see 
this  case  until  twenty-four  hours  after  birth. 

In  January,  1913,  I  gave  an  address  in  Detroit,  on  Diseases  of  the  Umbilicus 
before  the  Wayne  County  Medical  Society,  and  shortly  afterward  received  the 
following  letter  from  Dr.  H.  Wellington  Yates,  of  that  city: 

"Detroit,  February  1,  1913. 
"My  dear  Doctor.  A  short  time  ago  I  reported  a  case  of  congenital  hernia  of  the 
cord  in  the  new-born  at  the  Wayne  County  Medical  Society.  I  referred  in  my  paper 
to  three  other  cases  which  I  had  previously  observed,  together  with  references  to 
those  which  had  been  reported  in  the  literature  up  to  that  time.  After  the  meeting 
your  brother  Ernest  asked  me  if  I  would  not  send  you  a  brief  review  of  the  cases 
reported,  together  with  my  reprint  of  1907.  I  therefore  take  pleasure  in  inclosing 
these  data,  together  with  a  copy  of  the  picture  of  the  case  in  question.  I  feel  for- 
tunate in  having  had  four  cases  of  this  type  come  under  my  observation,  and  shall 
be  glad  if  you  can  use  the  picture  or  case  to  any  advantage. 

"Very  respectfully, 

"H.  Wellington  Yates." 

The  picture  referred  to  by  Dr.  Yates  is  reproduced  in  Fig.  197.  The  child  was 
born  on  January  11,  1913.  It  was  an  eight-month  child,  weighed  six  pounds,  and 
was  183^2  inches  long.  Occupying  the  greater  part  of  the  abdominal  wall  was  a 
hernial  protrusion.  This  was  14  cm.  broad  and  17  cm.  long.  The  child  was  other- 
wise well  formed.  Yates  says  that  he  was,  unfortunately,  unable  to  get  an  autopsy. 
The  walls  of  the  hernial  protrusion  were  almost  transparent,  and  apparently  con- 
sisted of  merely  amnion  and  peritoneum.  At  the  base  the  skin  was  continued  for 
a  short  distance  upon  the  sac.  From  what  Yates  could  gather,  the  larger  part  of 
the  intestine  was  in  the  sac. 

It  is  obvious  that  in  all  such  cases  the  only  chance  of  saving  the  child  is  by  oper- 
ating immediately  after  birth. 


CONGENITAL  NIPPING-OFF  OF  AN  UMBILICAL  HERNIAL  PROTRUSION. 

In  our  study  of  the  embryology  of  the  umbilical  region  we  have  seen  that  in  the 
early  months  a  large  part  of  the  small  bowel  lies  out  in  the  umbilical  cord.  Later 
the  intestine  recedes  into  the  abdomen.  The  cavity  in  the  cord  becomes  obliter- 
ated and  the  umbilical  ring  closes.  If  for  any  reason  the  bowel  becomes  adherent 
to  the  cavity  in  the  cord,  it  may  be  impossible  for  the  adherent  portion  to  pass  back 
into  the  abdomen.  If  such  a  condition  exists  and  the  umbilical  ring  closes,  we  shall 
have  one  or  more  loops  of  small  bowel  nipped  off  and  lying  on  the  abdominal  wall. 
Fortunately,  such  a  condition  is  very  rare.  That  it  may  occur,  however,  is  clearly 
shown  by  instances  reported  by  Kern  and  Ahlfeld. 

Kern*  reports  an  observation  made  by  Meckel.  Meckel,  in  examining  a  four 
months'  embryo  seven  inches  long,  found  malformations  of  the  lower  extremities 
and  of  the  heart,  and,  in  addition,  noted  that  the  intestine  was  divided  into  two 
halves,  which  did  not  communicate  with  each  other.  The  upper  or  stomach  half 
consisted  of  the  normal  stomach  and  of  11  inches  of  intestine.     The  intestine  was 

*  Kern,  Theo.:    Leber  die  Divertikel  des  Darmkanals.     Inaug.  Diss.,  Tubingen,  1874. 


464 


THE    UMBILICUS    AXD    ITS    DISEASES. 


Dhv 


Pv. 


for  the  most  part  of  normal  caliber,  but  for  a  space  of  one  inch  was  dilated  to  four 
times  the  normal  diameter.  It  then  gradually  became  smaller  and  passed  out 
through  the  umbilicus.  It  extended  outward  on  the  abdomen  one  inch,  and  then 
contracted  down  to  a  very  fine  thread.  This  passed  over  into  an  equally  fine 
thread,  which  was  continuous  with  the  upper  end  of  the  lower  portion  of  the  in- 
testinal canal.  This  is  a  good  example  of  the  nipping-off  of  the  intestine  outside 
the  abdomen  in  early  fetal  life.     In  this  case  the  umbilical  ring  was  still  open. 

Ahlfeld.*  in  1872.  was  asked  by  a  midwife  to  examine  a  child  with  a  rather  un- 
usual tumor.  The  child  was  six  hours  old,  had  passed  no  meconium,  and  cried 
constantly.     It  was  well  nourished  and  apparently  healthy.     At  the  navel  was  an 

irregular  tumor  the  size  of  an  apple 
,  v  \s  (Fig.  198).  This  tumor  was  attached 

^^y  to   the   umbilicus   by   a  very  thin 

:    jfk.       pedicle. 

It  was  clearly  evident  that  the 
tumor  consisted  of  a  nipped-off  in- 
testinal convolution.  The  individ- 
ual parts  of  this  were  firmly  adherent 
to  one  another  as  a  result  of  adhe- 
sions. The  tumor  was  hard  in  con- 
sistence, and  was  attached  to  the 
umbilicus  by  a  definite  pedicle. 

The  anus  was  well  formed,  and 
a  flexible  catheter  could  be  passed 
into  the  rectum  for  a  considerable 
distance.  The  rectum,  however,  con- 
tained no  meconium. 

The  tumor  was  removed  by  Pro- 
fessor Crede,  and  the  pedicle  was 
found  to  be  solid.  Under  the  exist- 
ing circumstances  it  was  deemed 
advisable  to  make  an  artificial  anus 
above  the  umbilicus,  but  the  child 
died. 

At  autopsy  it  was  found  that  the 
stomach  was  in  the  normal  position. 
The  duodenum  and  jejunum  were 
markedly  dilated,  while  the  portion 
of  the  intestine  between  the  enterostomy  opening  and  the  umbilicus  was  wide 
and  flat.  At  a  point  1  cm.  above  the  umbilicus  the  intestine  ended  blindly, 
and  from  there  to  the  umbilical  ring  there  was  nothing  but  a  delicate  strand  of 
mesentery. 

The  ascending  colon  passed  toward  the  pedicle  of  the  tumor  and  ended  blindly 
at  the  umbilical  ring.  The  remainder  of  the  bowel  to  the  anus  was  small  and  filled 
with  mucus. 

The  condition  was  due  to  the  fact  that  a  portion  of  the  intestine  lying  on  the 
abdomen  had  been  cut  off  by  closure  of  the  umbilical  ring. 

*  Ahlfeld:  Zur  Aetiologie  der  Darmdefecte  und  der  Atresia  ani.     Arch.  f.  Gyn.,  1873,  v,  230. 


Dnd. 

Fig.  19S. — Several  Loops  of  Bowel  which  Lay  Outside 
the  Umbilicus  and  were  Xipped  Off  Dubixg  Fetal 
Life.  The  Child  Lived  a  Short  Time  After  Birth. 
(After  Ahlfeld.) 

XI:,  Umbilical  elevation:  Vs,  umbilical  cord;  Dnd,  small 
bowel;  Died,  large  bowel;  Pv,  vermiform  appendix.  It  will 
be  noted  that  the  pedicle  of  this  tumor  is  very  narrow  at  the 
umbilicus.  It  then  expands  somewhat  and  again  becomes  ex- 
ceedingly narrow.  The  intestine  forming  this  mass  was  totally 
cut  off  from  the  portion  in  the  abdominal  cavity. 


UMBILICAL   HERNIA.  465 

Fortunately  this  complication  is  a  great  rarity.  Should  such  a  condition  be 
noted  at  birth,  immediate  operation  is  indicated.  After  the  umbilical  growth  has 
been  cut  off,  the  abdomen  should  be  opened  and  the  upper  and  lower  portions  of  the 
bowel  united  by  a  lateral  or  end-to-end  anastomosis. 


SMALL  UMBILICAL  HERNIA  AT  BIRTH. 

Hernise  of  this  character  are  relatively  common.  On  referring  to  Fig.  30 
(p.  27)  we  see  the  umbilical  weak  spot.  This  is  usually  to  the  right  of  the  umbilical 
vein,  and  above  the  umbilical  arteries.  In  this  connection  it  will  be  well  for  the 
reader  to  study  the  normal  appearance  of  the  umbilical  ring  as  viewed  from  the 
peritoneal  side  (p.  39).  A  careful  study  of  Plate  VI  will  give  a  clear  idea  of 
the  various  appearances  of  umbilical  herniae. 

In  the  young  infant  the  hernia  is  usually  not  over  1  to  2  cm.  in  diameter,  and 
when  an  appropriate  pad  is  applied,  as  a  rule,  gives  rise  to  little  trouble.  The  hernia 
tends  to  diminish  gradually  in  size  and  may  soon  disappear.  In  those  cases  in 
which  it  persists,  operation  may  be  deemed  advisable.  In  such  cases  a  small  longi- 
tudinal incision  may  be  made,  the  edges  of  the  ring  dissected  away,  and  the  surfaces 
carefully  approximated.  It  is  often  difficult  to  bring  the  peritoneum  together  as  a 
separate  layer,  on  account  of  its  extreme  delicacy  in  the  infant. 

One  of  the  most  ingenious  and  apparently  the  safest  method  of  curing  umbilical 
hernia  in  children  is  that  practised  by  Nota,  of  Turin.  His  method  has  been  clearly 
described  by  Brun. 

Brun*  expatiated  on  the  ease,  harmlessness,  and  effectual  outcome  of  the  method 
which  Nota,  of  Turin,  has  applied  since  1890  to  244  children  from  two  months  to 
nine  years  old.  The  earlier  the  operation,  the  smaller  the  hernia  and  the  better  the 
outcome.  An  elastic  cord  30  to  40  cm.  long  is  passed  around  the  base  of  the  hernia 
with  a  long  curved  needle  worked  through  horizontally  under  the  skin.  The  hernia 
is  then  reduced  and  held  in  place  with  the  finger,  while  the  elastic  cord  is  drawn 
tight  until  the  opening  is  entirely  obliterated.  The  ends  of  the  cord  are  then  held 
with  a  clamp  and  tied  with  silk  close  to  the  skin  and  cut  off,  the  short  ends  only  being 
left  protruding.  The  cord  is  drawn  taut  by  an  assistant,  while  the  reduced  hernia 
is  controlled  by  the  operator.  In  the  course  of  a  few  days  the  rubber  cord  gradually 
cuts  through  the  soft  tissue  in  its  grasp,  the  tissues  growing  together  in  its  wake  and 
thus  solidly  closing  the  opening.  After  twelve  or  fifteen  days  the  entire  rubber 
cord  comes  out  through  the  hole  in  the  skin  from  which  the  ends  protrude,  and  a 
thick,  solid  cicatrix  is  left  around  and  on  the  top  of  the  old  hernial  opening.  The 
dressings  are  not  disturbed  for  ten  days ;  then  a  new  dry  dressing  is  applied,  and  it 
is  wise  to  have  the  child  wear  a  simple  cloth  binder  around  the  abdomen  for  two  or 
three  months  afterward.  The  elastic  cord  is  sterilized  by  soaking  for  an  hour  in 
70  per  cent,  alcohol  containing  1.5  per  cent  glacial  acetic  acid.  No  complications 
of  any  kind  were  ever  observed  and  the  abdominal  wall  gradually  becomes  smooth 
and  supple.  Recurrence  was  observed  in  only  one  case — that  of  a  young  infant  with 
a  hernia  5  cm.  in  diameter.  The  hernia  recurred  during  an  attack  of  coughing,  but 
was  radically  cured  six  months  later  by  a  repetition  of  the  procedure.  General 
anesthesia  is  not  required  for  infants;  for  older  children  Nota  uses  a  few  whiffs  of 

*Brun:    Treatment  of  Umbilical  Hernia.     Jour.   Amer.   Med.  Assoc,   1912,  October  26, 
1578.     Abstract  from  Arch,  de  medecine  des  enfants,  Paris,  Sept.,  xv,  No.  9,  641. 
31 


466  THE    UMBILICUS    AND    ITS    DISEASES. 

ethyl  chloric!.     The  child  comes  to  at  once  after  the  little  operation,  which  never 
takes  over  six  minutes,  and  can  be  taken  home  if  kept  quiet. 

SEROUS  UMBILICAL  HERNIA. 

In  some  instances  in  which  the  abdomen  contains  a  large  quantity  of  ascitic 
fluid,  the  umbilicus  unfolds,  as  it  were,  and  becomes  distended,  so  as  to  suggest  an 
umbilical  hernia.  Indeed,  the  condition  has  been  termed  a  serous  umbilical  hernia. 
While  this  unfolding  of  the  umbilicus  is  not  very  common,  still  it  is  by  no  means  rare. 
The  reason  that  so  little  has  been  written  on  the  subject  is  evidently  due  to  the  fact 
that  the  accumulation  of  ascitic  fluid  in  the  umbilical  sac  has  been  looked  upon  as  a 
perfectly  natural  accompaniment  of  the  abdominal  distention  associated  with  a 
large  amount  of  ascitic  fluid. 

The  chief  articles  on  the  subject  are  those  of  Catteau  (1876),  Gauderon  (1876), 
Nicaise  (1881),  Ledderhose  (1890),  Gallant  (1906).  and  Perrin  (1910).  Nicaise 
referred  to  cases  reported  by  Brehm.  Van  Home,  Xuck,  and  Morgagni,  and  Led- 
derhose. to  one  recorded  by  Pineo-Hyannis. 

Catteau  examined  the  umbilicus  in  19  cases  of  ascites,  with  the  following  results: 

Slight  projection  of  the  umbilicus  in 11  cases 

Unfolding  of  the  umbilicus  in 3  cases 

True  umbilical  hernia  in 5  cases 

Perrin.  discussing  this  subject  in  1910,  said  that  in  32  cases  of  abdominal  ascites 
that  he  collected,  the  umbilicus  was  more  or  less  distended  in  9  cases.  He  also 
said  that  Bertrand,  in  28  cases  of  abdominal  ascites,  had  noted  umbilical  distention 
in  6  cases.     It  is  thus  clearly  evident  that  a  serous  umbilical  hernia  is  no  great  rarity. 

Clinical  Course.  —  The  majority  of  the  patients  concerning  whom  we 
have  records  were  women  between  thirty  and  sixty-five  years  of  age,  but  the  umbil- 
ical dilatation  may  also  occur  in  men.  The  ascites  was  usually  attributable  to 
chronic  nephritis,  cirrhosis  of  the  liver,  cardiac  dilatation,  or  to  a  combination  of 
these.  When  the  ascites  was  first  noticed,  no  change  in  the  umbilicus  was  detected, 
but  with  the  gradual  abdominal  distention  alterations  in  the  navel  developed. 

The  Umbilical  Tumor.  —  With  increased  abdominal  tension  the 
umbilicus  gradually  unfolds  and  a  small  hemispheric  prominence  is  noted.     This 


Plate  VI. 
Umbilical  Herxia. 

All  but  the  last  |  No.  11)  of  the  cases  of  umbilical  hernia  here  depicted  were  accidental  discoveries  made  during  the 
study  of  normal  umbilici  on  patients  in  the  hospital  wards.     The  results  of  this  study  are  pictured  on  Plates  I-IY. 

In  the  fetus  and  new-born  a  small  hernial  protrusion  at  the  upper  margin  of  the  umbilicus,  or  occasionally  on  the 
upper  right  or  left,  may  be  regarded  as  entirely  normal.  In  the  erect  posture  and  on  straining  or  coughing  this  small 
congenital  hernia  always  becomes  more  pronounced,  and  an  invisible  hernia  may  thus  become  demonstrable.  There  is 
marked  diastasis  of  the  recti  muscles  in  Xos.  1,  2,  3,  6. 

The  most  prominent  part  of  the  hernia  may  contain  the  umbilical  cicatrix  (Xos.  1,  3,  6);  the  usual  location  is 
below  the  hernia.  In  the  course  of  a  few  years  this  scar  gradually  becomes  effaced  (No.  3),  and  may  entirely  disappear 
(No.  5).  Pregnancy  also  has  a  tendency  to  smooth  out  the  folds  of  the  scar  (Xo.  4).  Immediately  afterbirth  the  skin 
over  the  navel  puckers  up  (No.  9)  and  remains  permanently  so  in  a  woman  who  has  had  many  children  (Xo.  7).  The 
herniae  in  both  Xos.  7  and  9  were  capable  of  much  distention,  but  were  drawn  while  devoid  of  contents.  No.  11  repre- 
sent- a  large  multilocular  hernia  filled  with  adherent  masses  of  omentum.  This  also  was  drawn  when  the  patient's 
abdominal  walls  were  relaxed.  For  the  further  appearances  in  this  case  see  Fig.  203,  p.  475,  and  Fig.  204,  p.  476. 
Xo-.  B  and  10  are  small  hernia  in  the  male  adult.  Xote  the  faint  parumbilical  vein  coursing  over  the  hernial  sac  in 
No.  8.  In  Xo.  10  the  hernia  was  covered  by  perfectly  white  skin.  The  patient  was  a  very  dark-skinned  negro,  who 
had  leukoplakia  over  the  thighs,  genitalia,  etc.     Thus  in  this  case,  there  was  a  white  umbilicus  in  a  coal-black  negro. 


UMBILICAL   HERNIA. 

PLATE  VI. 


467 


Female,  age  58,  IWIbe, 7  para  Female  ,   age  35  ,     ^6^+lbs.     5para 


468  THE    UMBILICUS    AND    ITS    DISEASES. 

may  be  very  small,  or  reach  2  or  3  cm.  in  diameter.  The  overhang  skin  looks  normal, 
and  often  the  sac  is  seen  to  contain  clear  fluid.  Sometimes,  however,  this  can  be 
detected  only  by  transmitted  light. 

As  the  intra-abdominal  pressure  continues,  the  umbilical  tumor  may  become 
as  large  as  a  goose's  egg  or  an  orange  and  may  be  either  hemispheric  or  lobulated. 
When  the  hernia  reaches  such  a  size,  the  overlying  skin  is  usually  greatly  stretched, 
and  the  fluid  contents  of  the  sac  are  easily  distinguishable.  The  fluid  from  the  sac 
can  usually  be  forced  back  into  the  abdomen  with  or  without  gurgling,  after  which 
the  finger  can  usually  make  out  the  sharp,  hard  margins  of  the  umbilical  ring. 
When  the  pressure  is  released,  the  fluid  at  once  flows  back  into  the  sac,  producing, 
as  pointed  out  by  Raciborski  (Xicaise),  a  peculiar  thrill. 

Occasionally,  when  the  sac  is  small,  it  may  also  contain  a  loop  of  small  intestine, 
but  where  the  abdominal  distention  is  marked,  it  contains  nothing  but  the  fluid. 
This  is  evidently  due  to  the  fact  that  when  the  abdominal  distention  is  marked,  the 
mesentery  of  the  small  bowel  is  not  long  enough  to  allow  the  intestine  to  reach  the 
abdominal  wall. 

As  a  rule,  the  serous  umbilical  hernia  is  only  an  incident  in  the  course  of  the 
nephritis,  cirrhosis,  or  cardiac  disease.  Occasionally,  however,  the  local  condition 
may  attract  some  attention.  Catteau  mentioned  a  case  of  Morgagni's  in  which 
an  umbilical  tumor  the  size  of  a  goose's  egg  broke,  each  day  discharging  limpid  fluid. 
It  finally  healed.  According  to  Nicaise,  rupture  of  the  umbilicus  distended  by 
ascitic  fluid  is  very  rare,  as  he  knew  of  only  two  observations,  those  of  Brehm  and 
Van  Home.  Ledderhose  mentions  a  case  recorded  by  Pineo-Hyannis,  in  which  the 
ascitic  fluid  escaped  from  the  umbilicus  and  recovery  took  place. 

Perrin  reported  a  case  of  a  man,  aged  fifty-one,  suffering  from  hepatic  cirrhosis. 
The  umbilical  sac  was  as  big  as  an  orange.  It  ruptured  on  the  right  side,  but  cica- 
trized and  the  patient  was  afterward  tapped  15  times,  an  average  of  24  pints  of 
ascitic  fluid  being  drawn  off. 

As  a  rule,  the  subsequent  history  of  the  patient  will  depend  entirely  upon  the 
pathologic  lesion  responsible  for  the  ascites.  In  a  case  reported  by  Perrin,  a  woman 
aged  fifty-two  had  a  serous  umbilical  hernia.  This  ruptured,  the  sac  remaining  open 
and  shrunken.     Erysipelas  developed  around  the  umbilicus  and  proved  fatal. 

Perrin  has  studied  the  umbilicus  in  normal  and  ascitic  subjects  and  finds  that 
at  least  three  causative  factors  must  be  taken  into  account.  In  the  first  place,  the 
umbilical  ring  varies  greatly  in  diameter.  In  the  second  place,  the  ring  is  much 
more  readily  distended  in  some  cases  than  in  others,  as  its  fibrous  and  connective 
tissue  may  be  abundant  and  firmly  welded  together  or  loose  in  texture;  and,  finally, 
the  obturator  membrane  varies  greatly  in  strength. 

Cases  of  Serous  Umbilical  Hernia. 

From  the  following  cases  the  reader  may  gather  a  clear  idea  of  the  clinical  pic- 
ture. The  small  number  of  cases  here  recorded  is,  however,  no  index  of  the  fre- 
quency of  serous  umbilical  hernia. 

Prominences  at  the  Umbilicus  Associated  with  In- 
terstitial Nephritis,  Cirrhosis  of  the  Liver,  and  As- 
cites.* —  An  alcoholic  woman,  aged  thirty-two,  who  had  interstitial  nephritis 

*  Catteau:  De  l'ombilic  ct  de  ses  modifications  dans  les  cas  de  distension  de  l'abdomen. 
Thfefde  Paris.  1*70,  obs.  11,  12,  13. 


UMBILICAL   HERNIA. 


469 


and  cirrhosis  of  the  liver,  had  also  had  ascites  for  four  weeks.  The  umbilicus  was 
hemispheric,  transparent,  and  3  to  4  cm.  in  diameter.  The  finger  could  be  easily 
introduced  into  the  umbilical  ring. 

A  patient,  thirty-one  years  of  age,  who  was  suffering  from  Bright's  disease,  had 
an  irregular  umbilical  tumor,  6  by  4  by  4.5  cm.  It  was  lobulated,  and  the  over- 
lying skin  was  transparent. 

A  woman,  aged  forty-nine,  had  had  marked  abdominal  enlargement  for  two 
months,  and  for  six  weeks  had  had  at  the  umbilicus  a  tumor 
3  cm.  in  diameter. 

An  Umbilical  Protrusion  Due  to  Ab- 
dominal Ascites.- —  Gauderon*  reports  a  case  coming 
under  Guyot's  observation.  The  patient  was  a  vigorous  man, 
aged  thirty-five,  who  entered  Guyot's  clinic  with  definite  symp- 
toms of  Bright's  disease,  characterized  by  albuminuria,  edema 
of  the  legs  and  of  the  abdominal  walls,  with  moderate  ascites. 
The  ascites  increased.  The  umbilicus  was  distended,  and  on 
March  12, 1876,  an  umbilical  intestinal  hernia  developed.  The 
hernia  was  irreducible,  and  gurgling  could  be  made  out.  This 
man  had  never  had  an  umbilical  hernia  before  and  had  never 
used  a  bandage. 

By  April  3d  of  the  same  year  the  intestine  had  disappeared 
from  the  hernial  sac  and  the  site  was  occupied  by  serous  peri- 
toneal fluid.  During  this  period  the  ascites  had  increased. 
The  patient  left  the  hospital  at  his  own  request  on  April  20th. 


Serous  Umbilical  Hernia  in  Children. 

Very  few  cases  have  been  recorded,  simply  because  ascites 
is  much  rarer  in  children  than  in  adults.  Were  ascites  just  as 
frequent  in  children,  we  would  have  a  much  larger  percentage 
of  serous  umbilical  hernise  in  the  child,  as  in  early  life  the  um- 
bilicus gives  way  very  readily.  I  shall  here  give  a  typical  ex- 
ample of  an  umbilical  hernia  in  an  infant : 

Baby  H.  Seen  in  consultation  with  Dr.  Vogler  at  the 
Church  Home  and  Infirmary,  Baltimore,  November  14,  1910. 
The  child  is  eight  months  of  age  and  has  marked  abdominal  dis- 
tention. Two  weeks  ago  an  umbilical  hernia  developed.  The 
hernial  sac  is  about  2  cm.  in  diameter  and  projects  at  least  1.5 
cm.  from  the  abdominal  wall  (Fig.  199).  The  skin  over  the 
umbilicus  shows  marked  tension  and  is  shiny;  and  one  can  de- 
tect clear  fluid  in  the  hernial  sac.  On  percussion  there  is  a  dis- 
tinct wave  of  fluctuation  throughout  the  entire  abdomen,  and  there  is  also  much 
enlargement  of  the  liver.  Two  or  three  days  ago  inguinal  hernise  developed  on 
both  sides.  After  much  consideration  it  was  felt  wiser  not  to  let  the  fluid  out  for 
fear  that  the  child  might  develop  a  general  peritonitis.  He  was  taken  home,  but 
notwithstanding  the  most  careful  nursing  he  grew  worse.  He  developed  pneumonia 
about  two  months  after  leaving  the  hospital  and  died. 

*  Gauderon:    De  la  peritonite  idiopathique  aigue  des  enfants;    de  sa  terminaison  par  sup- 
puration et  par  evacuation  du  pus  a  travers  rombilic.     These  de  Paris,  1876,  No.  148,  51. 


Fig.  199.— A  Serous 
Umbilical  Her- 
nia. 

This  represents  the 
abdominal  contour  in 
the  umbilical  region  of  a 
child  eight  months  old. 
The  child's  liver  was 
markedly  enlarged  and 
the  abdomen  full  of  as- 
citic fluid.  The  umbili- 
cus was  unfolded  and 
formed  the  projection 
here  depicted.  The 
overlying  skin  was  very 
thin,  and  the  fluid  in  the 
umbilical  sac  could  be 
clearly  seen. 


470  THE    UMBILICUS    AND    ITS    DISEASES. 

Escape  of  Serous  Fluid  from  the  Umbilicus  in  a  Case  of  Tuberculous  Peritonitis. 
Ledderhose*  reports  an  observation  by  Henoch  on  an  eight-year-old  boy.  On 
two  occasions,  on  account  of  marked  ascites,  several  liters  of  fluid  had  been  removed 
by  puncture  and  from  time  to  time  clear  serum  escaped  from  the  distended  umbili- 
cus. This  flow  was  followed  by  a  diminution  in  the  abdominal  distention.  Three 
months  later,  as  a  result  of  tuberculous  meningitis,  the  child  died.  At  autopsy 
tuberculosis  of  the  peritoneum  was  found.  In  the  abdominal  cavity  at  the  time  of 
autopsy  there  were  only  about  100  c.c.  of  clear,  light  yellow  fluid. 

Serous  Umbilical  Hernia  Associated  with  an  Ovarian  Cyst. 

We  have  records  of  two  such  cases,  those  reported  by  Catteau  and  Gauderon.  If 
there  be  ascites  associated  with  an  ovarian  tumor,  the  development  of  serous  umbili- 
cal hernia  is  easily  explained.  It  is  also  easily  understandable  that  if,  through 
injury,  rupture  of  the  ovarian  cyst  occurs,  the  free  ovarian  fluid  may  pass  into  an 
umbilical  hernia. 

An  Ovarian  Cyst  Associated  with  Umbilical  Swell- 
ing. —  Catteau,  in  Case  16,  refers  to  a  woman  forty-five  years  of  age,  who  had 
had  an  ovarian  cyst  for  ten  years.  After  falling  on  her  back  she  vomited,  and  a 
tumor  was  noted  at  the  umbilicus.  Two  months  later  there  was  an  escape  of  fluid 
through  an  umbilical  opening. 

A  Serous  Umbilical  Hernia  Associated  with  an  Ova- 
rian Cyst.j  —  This  case  was  communicated  to  Gauderon  by  his  friend  Dus- 
saussay:  Catherine  S.,  aged  sixty-five,  entered  the  service  of  Dr.  Millard,  April 
21,  1876.  On  admission  she  was  found  to  have  an  enormous  abdominal  tumor, 
which  had  first  been  noticed  six  years  previously  and  diagnosed  as  an  ovarian  cyst. 
It  was  complicated  by  the  presence  of  ascitic  fluid.  When  the  patient  entered  the 
hospital  there  was  a  hemispheric  tumor  at  the  umbilicus.  It  was  fluctuant  and 
reducible  without  gurgling.  After  reduction  the  finger  met  with  a  hard  umbilical 
ring.  The  tumor  was  supposed  to  be  a  serous  hernia  complicating  ascites.  The 
patient  said  that  this  small  tumor  had  existed  for  more  than  a  year.  Several 
days  later  she  developed  peritonitis  and  died  on  May  2,  1876. 

Autopsy  revealed  a  multilocular  ovarian  cyst  on  the  left  side.  There  were 
traces  of  peritonitis.  At  the  umbilicus  there  was  a  true  serous  hernia.  The  um- 
bilicus was  distended  in  the  form  of  a  hernia  the  size  of  a  large  walnut,  and  the 
hernial  sac  was  lined  with  peritoneum.  The  umbilical  ring  itself  was  1  cm.  in 
diameter.     The  peritoneum  of  the  sac  was  whitish  and  opalescent. 

A  Serous  Umbilical  Hernia  Associated  with  a  Large  Cystic  Myoma  and  Marked 

Abdominal  Ascites. 

While  preparing  this  chapter  the  following  case  came  under  my  care  at  the 
Johns  Hopkins  Hospital: 

Gyn.  No.  18101,  Gen.  No.  81548.  E.  G.,  colored,  aged  thirty-four,  was  admitted 
fco  Ward  0  January  16,  1912,  complaining  of  abdominal  distention  and  shortness  of 
breath.  She  has  always  enjoyed  good  health  previous  to  the  present  illness. 
During  the  last  winter  she  has  had  several  colds,  which  were  accompanied  by  per- 
sistent cough  and  some  expectoration.  Since  September,  1911,  the  patient  has 
had  periods  of  suppression  of  urine,  which  have  lasted  for  twenty-four  hours,  and  for 
*  Ledderhose:   Deutsche  Chirurgie,  1890,  Lief.  45  b.  t  Gauderon:  Op.  cit.,  obs.  15. 


UMBILICAL    HERNIA.  471 

the  last  four  months  there  has  been  marked  constipation.  EleveD  months  ago  the 
patient  noticed  that  her  abdomen  was  increasing  in  size.  It  has  steadily  grown 
larger,  and  she  suffers  a  good  deal  from  dyspnea.  The  limbs  have  become  so 
swollen  lately  that  whenever  the  patient  has  had  to  get  into  bed  she  has  been 
obliged  to  have  some  one  lift  her  legs  for  her.  She  has  had  very  little  abdominal 
pain,  her  main  complaint  being  shortness  of  breath  and  abdominal  swelling. 

Present  Condition. — The  patient  is  a  sparely  nourished,  rather  emaciated 
negress.  She  has  some  trouble  with  dyspnea  and  reclines  in  bed  on  several  pillows. 
The  abdomen  is  markedly  distended  and  there  is  an  umbilical  hernia.  The  abdo- 
men is  full  and  somewhat  rounded.  The  distention  extends  from  the  xiphoid  to  the 
symphj'sis.  There  is  a  definite  bowing  of  the  xiphoid  cartilage.  It  is  pressed  al- 
most at  right  angles  to  the  sternum.  No  masses  are  to  be  made  out  in  the  abdomen 
on  deep  palpation.  There  is  considerable  edema  throughout  the  lower  half  of  the 
abdomen  and  marked  pitting  on  pressure.  A  definite  fluctuation  wave  is  made 
out.     With  the  patient  in  the  dorsal  position,  the  dulness  extends  to  either  flank. 

Operation. — Abdominal  hysteromyomectomy,  January  17,  1912. 

The  umbilicus  was  dilated,  forming  a  hernia  about  2  cm.  in  diameter.  The  walls 
here  were  very  thin,  and  the  sac,  which  was  evidently  filled  with  fluid,  projected  as  a 
little  dome  about  2  cm.  from  the  surface  of  the  abdomen.  I  picked  up  the  hernial 
sac  on  either  side  with  forceps  and  opened  it.  A  rubber  hose  was  firmly  pressed 
over  the  opening,  and  we  removed  over  17  liters  of  ascitic  fluid  from  the  general 
abdominal  cavity.  The  incision  was  then  increased  in  size,  and  I  saw  what  appeared 
to  be  an  ovarian  cyst,  with  a  small  opening  in  it.  I  hooked  my  finger  into  this  and 
raised  it  up  still  more.  On  getting  it  out  I  was  surprised  to  find  that,  instead  of 
an  ovarian  cyst,  we  had  a  cystic  myoma,  which  projected  from  the  posterior  surface 
of  a  myomatous  uterus.  A  supravaginal  hysterectomy  was  done,  and  the  abdomen 
closed  without  drainage.     Convalescence  was  uneventful. 

Path  Xo.  16947.  The  multinodular  myomatous  uterus  is  approximately  12  cm. 
long,  10  cm.  broad,  10  cm.  in  its  anteroposterior  diameter.  The  uterus  contains 
numerous  subperitoneal  and  interstitial  nodules.  Projecting  from  the  fundus  is  a 
cystic  nodule,  approximately  14  cm.  in  diameter.  At  its  upper  end  is  a  small  hole 
from  which  serous  fluid  oozes.  The  tumor  on  section  is  found  to  be  partly  cystic, 
partly  solid.  There  are  numerous  loculi  which  open  into  one  another,  and  there 
are  bands  of  tissue  running  from  side  to  side  in  the  main  cyst.  The  right  tube  is  the 
seat  of  a  hydrosalpinx,  and  the  entire  mass  is  enveloped  in  adhesions.  On  the  left 
side  the  tube  is  9  cm.  long  and  has  been  converted  into  a  hydrosalpinx. 


UMBILICAL  HERNIA  IN  THE  ADULT. 

For  a  general  consideration  of  this  subject  the  reader  is  referred  to  the  text- 
books on  surgery.  I  shall  mention  only  the  salient  facts  and  refer  to  certain  points 
that  have  particularly  impressed  me. 

Umbilical  hernia  in  the  adult  seems  to  be  much  more  prevalent  in  the  female 
than  in  the  male,  and  not  infrequently  is  noted  after  the  abdominal  distention  con- 
sequent to  pregnancy.  It  is  more  common  in  stout  women  than  in  thin  persons. 
This  is  probable  partly  due  to  the  fact  that,  when  individuals  take  on  adipose 
tissue  externally,  there  is  a  coincident  increase  in  the  amount  of  fat  in  the  omen- 
tum and  mesentery,  and  therefore  an  increased  tension  on  the  abdominal  wall. 


472 


THE    UMBILICUS    AND    ITS    DISEASES. 


With  the  increase  of  adipose  tissue  there  is  an  increased  tendency  toward  a  pendu- 
lous condition  of  the  abdomen.  If  the  umbilical  hernia  is  small  and  can  be  readily 
reduced,  the  patient  often  experiences  little  or  no  discomfort.  In  those  cases  in 
which  the  hernia  reaches  a  diameter  of  3  to  4  cm.,  when  the  omentum  is  adherent 


Fig.  200. — Freeing  the  Umbilical  Hernial  Sac  From  the  Abdomen.     (Head  of  Patient  Below,  Stmphysis 

Above.) 
In  this  case  an  elliptic  abdominal  incision  has  been  made  around  the  hernia  from  above  downward,  and  the  adipose 
tissue  has  been  reflected  back  on  either  side  until  the  neck  of  the  sac  and  the  surrounding  abdominal  fascia  are  clearly 
exposed.  In  those  cases  in  which  there  is  much  redundancy  and  it  is  deemed  advisable  to  remove  a  large  area  of  adipose 
tissue,  the  skin  incisions  should  be  from  side  to  side.  When  the  neck  of  the  sac  is  well  exposed,  the  fascia  is  cut  through 
just  above  the  sac, — above,  because  there  are  few  if  any  adhesions  at  this  point, — and  a  finger  is  introduced  as  indicated. 
With  the  finger  as  a  guide  the  sac  is  cut  free  all  the  way  around.  The  hernial  mass  is  now  isolated,  and  can  be 
lifted  well  away  from  the  abdominal  wall  and  then  walled  off  with  gauze.  The  sac  is  now  slit  open  from  neck  to  base. 
If  it  contains  intestinal  loops,  these  are  liberated  and  returned  into  the  abdomen.  Where  the  omentum  is  very  loosely 
attached,  it  is  also  liberated  and  returned  to  the  abdominal  cavity,  but  when  it  is  densely  adherent,  the  extra-abdominal 
portion  is  tied  off  and  removed  with  the  sac.     For  the  closure  of  the  hernial  opening  see  Figs.  201  and  202. 


and  the  abdomen  is  pendulous,  the  patient  experiences  a  dragging  sensation  if  on 
her  feet  much.     This  is  evidently  due  to  tension  on  the  transverse  colon. 

When  a  small  umbilical  hernia  exists,  the  fat  lobules  occasionally  present  in 
the  ring  may  increase  in  volume,  thereby  stretching  the  ring. 


UMBILICAL   HERNIA. 


473 


When  the  omentum  has  been  incarcerated  for  a  considerable  time,  there  may  be 
edema  of  the  surrounding  abdominal  wall  and  a  tendency  for  the  more  prominent 
parts  of  the  hernia  to  become  excoriated. 


Fig.  201. — Clostjke  of  the  Hernial  Opening  at  the  Umbilicus. 
A  row  of  mattress  sutures  consisting  of  kangaroo  tendon,  chromicized  catgut,  or  silk,  as  the  operator  may  prefer, 
are  so  placed  that  the  lower  flap  a  is  drawn  well  up  under  the  upper  flap  6.  Before  tying  these  the  second  row  of  mat- 
tress sutures  is  passed  through  the  lower  flap  a.  They  are  inserted  now  because,  with  the  abdomen  opened,  one  can 
take  a  much  deeper  bite,  the  finger  serving  as  a  guide  to  the  depth  of  their  insertion.  When  they  are  placed  after  the 
first  row  has  been  tied,  the  operator  rarely  grasps  enough  tissue,  as  he  is  afraid  of  piercing  the  underlying  intestine. 
After  the  first  row  of  mattress  sutures  has  been  tied,  the  ends  of  the  second  row  of  sutures  are  passed  through  the  edge 
of  the  upper  flap  and  tied.  Needles  have  been  placed  on  the  ends  of  each  of  these  sutures  to  facilitate  the  understanding 
of  the  procedure.  In  actual  practice  each  pair  of  suture  ends  is  temporarily  clamped  with  forceps  and  rethreaded 
after  the  first  row  has  been  tied.     (For  the  appearance  of  the  ring  when  closed  see  Fig.  202.) 


It  is  in  the  small  hernia?  that  a  knuckle  of  gut  is  liable  to  become  incarcerated, 
and  the  patient  then  speedily  develops  the  characteristic  symptoms  of  a  partial 
or  complete  intestinal  obstruction. 

Treatment.  —  Given  a  thin  patient,  the  operation  is  usually  easy.  Un- 
fortunately, however,  the  majority  of  these  patients  are  stout,  many  of  them  quite 


474 


THE    UMBILICUS    AND    ITS    DISEASES. 


obese,  and  show  a  marked  tendency  toward  emphysema.  Such  patients  are  prone 
to  develop  postoperative  lung  complications,  and  this  danger  should  be  thoroughly 
considered  before  any  operative  interference  is  undertaken.  I  invariably  follow 
the  postoperative  course  of  such  a  case  for  several  days  with  some  concern.  The 
preparatory  treatment  of  these  cases  has  recently  been  admirably  outlined  by 
Alexius  McGlannan  (Proc.  Southern  Surg,  and  Gyn.  Assoc,  1914,  xxvii,  311). 

The  radical  operation  for  umbilical  hernia  may  be  a  most  difficult  procedure  or  a 
relatively  simple  operation,  depending  in  large  measure  on  the  manner  in  which  it 
is  performed.  So  far  as  my  personal  experience  goes,  it  is  wise  to  make  an  elliptic 
incision  from  above  downward  or  from  side  to  side.  A  wide  area  is  usually  outlined 
and  freed  down  to  the  fascia.  The  hernia  and  the  flap  of  fat  are  dissected  free  until 
the  neck  of  the  sac  stands  out  clearly  on  all  sides.     A  small  incision  is  then  made 


Fig.  202. — Closure  of  the  Hernial  Opening  at  the  Umbilicus. 
For  the  first  steps  in  the  closure  see  Fig.  201.     The  first  row  of  sutures  has  been  tied,  and  the  second  row  is  nearly 

completed. 


through  the  fascia  of  the  abdominal  wall,  at  a  point  just  above  the  sac — above, 
because  the  omentum  is  here  usually  free  from  adhesions.  The  opening  in  the 
abdomen  should  be  just  large  enough  to  admit  the  finger.  After  the  finger  has  been 
introduced,  it  acts  as  a  guide,  and  the  operator  cuts  down  on  it,  severing  the  sac 
all  the  way  round  just  at  its  point  of  attachment  to  the  abdominal  wall  (Fig.  200). 

When  the  neck  of  the  sac  has  been  cut  loose,  the  hernia  can  be  lifted  out  and 
laid  on  a  large  piece  of  gauze.  After  seeing  that  no  intestinal  loops  are  incarcerated 
in  the  hernia,  the  operator  now  slits  up  the  wall  of  the  sac  to  see  if  the  omentum  can 
be  saved.  Sometimes  this  is  possible;  in  other  cases,  however,  the  omentum  is  so 
densely  adherent  to  the  sac  that  it  must  be  removed  with  the  sac. 

Unless  one  has  carefully  dissected  a  series  of  large  umbilical  hernise,  he  has  little 
idea  of  the  many  alcoves  and  channels  running  off  from  the  main  cavity  (Fig.  204). 
After  the  omentum  has  been  replaced  or  tied  off,  as  the  case  may  be,  the  peri- 


UMBILICAL    HERNIA. 


475 


toneum  is  closed  and  the  fascia  overlapped  from  above  downward,  as  advocated  by 
Dr.  Win.  J.  Mayo,  Dr.  Charles  P.  Xoble,  and  others.  The  fascia  from  the  lower 
part  of  the  abdominal  ring  is  drawn  up  in  under  the  fascia  of  the  upper  wall  (Fig. 
201).  Two  rows  of  mattress  sutures  in  the  fascia  usually  suffice  to  give  a  perma- 
nent cure  (Fig.  202).     The  fat  and  skin  are  then  approximated.     It  would  be  im- 


Fig.  203. — Ax  Umbilical  Herxia  Associated  with  Marked  Prolapsus  of  the  Abdominal  Wall. 

The  umbilical  hernia  was  about  10  cm.  in  diameter.     The  elliptic  transverse  incision  is  indicated  by  the  black  line.     The 

lower  figure  indicates  the  shape  and  size  of  the  piece  of  adipose  tissue  removed. 


possible  to  lay  too  much  stress  on  the  importance  of  freeing  the  neck  of  the  sac 
from  the  abdominal  wall  before  attempting  to  unravel  the  sac-contents,  and  upon 
the  ease  with  which  this  can  be  accomplished  by  using  the  finger  in  the  abdomen 
as  a  guide  in  its  liberation.  I  have  used  this  method  for  years,  and  found  it  par- 
ticularly useful  in  the  following  case: 


476 


THE    UMBILICUS    AND    ITS    DISEASES. 


Mrs.  C.  J.,  aged  thirty-five,  admitted  to  the   Church   Home   and  Infirmary 
on  February  11,  1914.     This  patient  has  had  five  children,  the  youngest  being 


Fig.  204. — An  Umbilical  Hernia  and  a  Markedly  Pendulous  Abdomen  in  a  Patient  Weighing  464  Pounds. 
This  is  a  sketchy  outline  of  the  condition  found.  With  the  patient  standing,  the  dependent  portion  of  the  abdomen 
reached  the  knees.  As  the  omentum  was  adherent  to  the  hernial  sac,  the  transverse  colon  was  markedly  drawn  down- 
ward. The  dotted  line  indicates  the  line  of  dissection,  the  fat  of  the  abdominal  wall  being  removed  down  to  the  fascia. 
The  hernial  sac  was  divided  into  numerous  secondary  cavities.  This  is  particularly  well  seen  in  the  upper  sketch, 
which  was  drawn  from  the  hernial  sac  after  removal. 


eight  months  old.  At  the  time  of  her  marriage  she  weighed  225  pounds.  Her 
weight  today  is  464  pounds.  She  complains  of  an  umbilical  hernia  which  is  about 
10  cm.  in  diameter.     When  on  her  feet,  the  abdomen  hangs  down  to  her  knees. 


UMBILICAL   HERNIA. 


477 


The  dragging  sensation  caused  thereby  is  so  great  that  she  is  forced  to  keep  off  her 
feet  as  much  as  possible.  I  was  unwilling  to  operate,  and  explained  the  danger  to 
her  husband.  The  patient,  who  is  still  a  relatively  young  woman,  said  that  she 
was  becoming  a  semi-invalid  and  insisted  that  she  be  relieved. 

Operation. — February  12,  1914.  On  account  of  the  marked  redundancy  of  the 
abdominal  wall,  we  decided  to  relieve  her  of  a  large  quantity  of  fat,  together  with 
the  hernia,  as  advocated  by  Dr.  Howard  A.  Kelly.  Accordingly,  a  large  transverse 
elliptic  area  was  outlined  (Fig.  203).  This  area,  when  measured  on  removal,  was 
36  inches  from  side  to  side  and  19  inches  from  above  downward.  The  adipose  tissue 
of  the  huge  flap  was  dissected  from  the  fascia  of  the  abdominal  wall  all  around  as  far 


Fig.  205. — The  Abdominal  Scar  After  the  Removal  of  a  Vert  Large  Area  of  Fat. 
The  abdominal  wound  gave  a  transverse  measure  of  36  inches.     After  the  wound  had  healed,  the  scar  had  con- 
tracted down  to  27  inches.     Note  the  size  of  the  patient  relative  to  that  of  the  bed.     This  was  of  the  three-quarter  size, 
the  ordinary  hospital  bed  being  too  small  for  the  patient. 


as  the  neck  of  the  hernia.  Then,  with  a  finger  in  the  abdomen  as  a  guide,  the  neck 
of  the  sac  was  cut  all  around  at  its  margin  with  the  abdominal  wall.  The  dotted 
line  in  Fig.  204  indicates  the  line  of  the  dissection.  The  omentum  in  the  sac  was 
so  intimately  blended  with  the  walls  of  the  sac  that  this  portion  of  the  omentum  was 
cut  off  and  removed  with  the  sac  and  redundant  tissue.  Max  Brodel,  in  the  upper 
sketch  in  Fig.  204,  has  clearly  shown  the  neck  of  the  sac  and  the  numerous  chambers 
passing  off  from  it.  The  hernial  opening  was  closed  by  the  Mayo  method — by 
sliding  the  fascia  of  the  lower  margin  of  the  opening  up  under  that  of  the  upper 
margin.  We  used  kangaroo  tendon  for  the  mattress  sutures,  and  after  the  first 
row  had  been  placed  and  tied,  the  edges  of  the  upper  flap  were  fastened  down  with 


478  THE    UMBILICUS    AND    ITS    DISEASES. 

a  second  row  of  mattress  sutures.  The  abdominal  wound  was  now  approximated 
with  interrupted  silver-wire  and  silkworm-gut  sutures.  Each  suture  included  the 
skin,  fat,  and  a  little  of  the  fascia.  Accurate  skin  approximation  was  obtained  by 
using  continuous  black  silk.  At  each  end  of  the  incision  a  protective  drain  was 
introduced. 

The  patient  made  a  speedy  recovery,  and  the  abdominal  wound  healed  per- 
fectly. When  the  stitches  were  removed,  the  abdominal  incision  had  contracted 
down  until  it  measured  only  27  inches  from  side  to  side  (Fig.  205).  Eight 
months  later  the  patient  was  in  excellent  health. 

Hernije  Through  Weak  Spots  in  the  Abdominal  Wall. 
Where  the  hernia  develops  from  a  weak  spot  near  the  umbilicus  it  closely 
resembles  an  umbilical  hernia,  and  clinically  may  be  considered  as  such.     This 
subject  is  discussed  in  detail  on  p.  55. 


Fig.  206. — An  Umbilical  Ctst.     (After  Gallant.) 
A  Scotch  terrier  developed  a  small  umbilical  hernia  when  about  four  months  old.     It  enlarged  so  that  the  dog 
had  to  drag  itself  about  on  the  floor.     The  cyst  became  larger  and  somewhat  inflamed.     The  skin  grew  so  thin  that  the 
fluid  could  be  seen  in  the  center.     The  ring  had  evidently  contracted  down  on  the  omentum,  and  the  peritoneal  fluid 
had  accumulated. 

CYSTS  OF  THE  UMBILICUS. 

When  an  umbilical  hernia  exists,  as  a  matter  of  course  the  peritoneum  is  carried 
ahead  of  the  hernial  mass  and  hence  lines  the  hernial  sac.  If  by  any  chance  the 
hernial  sac  becomes  completely  separated  from  the  abdominal  cavity,  peritoneal 
fluid  may  accumulate  in  this  sac,  producing  a  cystic  tumor.  Gallant  and  Walz 
report  cases  clearly  demonstrating  such  a  phenomenon.  Gallant's*  subject  was  a 
Scotch  terrier  that  developed  a  small  umbilical  tumor  when  four  months  old.  The 
hernia  enlarged,  and  the  puppy  had  to  drag  himself  about  the  floor  on  his  abdomen. 
The  cystic  mass  increased  in  size  and  became  somewhat  inflamed.  The  skin  cover- 
ing it  grew  so  thin  that  the  fluid  in  the  sac  could  be  readily  seen.  At  operation  the 
condition  depicted  in  Fig.  206  was  found.  Firmly  plugging  the  hernial  ring  was  a 
small  piece  of  omentum,  and  the  peritoneal  lining  had  doubtless  secreted  the  fluid 
found  in  the  sac. 

Walz,f  on  January  6,  1902,  saw  a  gunmaker,  aged  fifty-one,  lying  in  bed  com- 

*  Gallant:  Disorders  of  the  Umbilicus  with  Special  Reference  to  the  New-born  and  the 
Infant;  III  Umbilical  Infections.     Internat.  Clinics,  1907,  17.  series,  i,  1.51. 

t  Walz,  Karl:  Ein  Beitrag  zur  Kenntnis  der  Nabelcysten.  Munch,  med.  Wochenschr., 
1902,  xlix,  959. 


UMBILICAL    HERNIA.  479 

plaining  of  pain  in  the  umbilical  region  and  of  diarrhea.  For  several  years  the 
patient  had  noticed  a  tumor  the  size  of  a  walnut  at  the  umbilicus.  This  could  be 
readily  pressed  back,  but  coughing  caused  it  to  reappear.  For  twenty-four  hours 
the  patient  had  had  increasing  pain  at  the  umbilicus,  and  the  tumor  had  rapidly 
increased  in  size  and  could  not  be  reduced.  Since  that  time  there  had  been  diarrhea, 
but  no  vomiting.  His  temperature  was  37.6°  C;  pulse  90  and  regular.  In  the 
umbilical  region  was  a  half-ball-shaped  tumor,  the  size  of  a  hen's  egg,  directly  to  the 
left  of  the  umbilicus.  It  overlapped  and  covered  the  umbilicus.  The  overlying 
skin  was  movable  and  somewhat  reddened. 

Walz  thought  that  the  nodule  was  due  to  incarcerated  omentum.  At  operation 
it  was  found  to  contain  clear  serous  fluid  supposed  to  be  peritoneal  fluid.  After  the 
fluid  had  escaped,  the  cavity  was  found  to  be  empty.  The  walls  were  0.5  to  1  mm. 
thick,  and  the  sac  ended  in  a  pedicle  the  thickness  of  a  lead-pencil,  which  passed 
into  the  umbilical  ring.  There  was  no  opening  into  the  abdomen.  The  sac  was 
tied  off  and  removed,  and  the  patient  made  a  good  recovery. 

Microscopic  examination  of  the  sac  shows  that  it  was  composed  of  fibrous  tissue 
with  an  inner  wall  of  granulation  tissue ;  there  were  a  few  polymorphonuclear  leu- 
kocytes, and  no  evidence  of  epithelium.  Walz  thought  it  possible  that  a  hernial 
sac  had  been  nipped  off  from  the  abdomen  as  a  result  of  an  inflammatory  process, 
and  that  the  fluid  had  accumulated.     This  seems  to  be  the  correct  interpretation'. 

These  two  cases  clearly  demonstrate  how  small  umbilical  cysts  may  be  the  end- 
result  of  old  hernise. 

Caruso*  reports  an  instance  of  an  umbilical  cyst  the  size  of  a  chestnut,  in  a 
woman  forty-two  years  of  age.  On  histologic  examination  it  was  found  to  be  lined 
partly  with  cuboid,  partly  with  low  cylindric  epithelium.  He  called  it  a  cystic 
adenoma.  Without  seeing  the  specimen  I  should  hesitate  to  classify  it,  but  we 
know  that  the  cells  covering  the  peritoneal  surface,  when  protected,  frequently 
become  cuboid. 

Ledderhose,f  in  his  masterly  article  on  surgical  diseases  of  the  umbilicus,  refers 
to  the  scanty  mention  of  umbilical  cysts.  He  then  describes  Lotzbeck's  case,  in 
which  a  multilocular  tumor  the  size  of  a  fist  was  removed  by  Brun  from  the  umbili- 
cus in  a  child  two  and  one-half  years  old.  It  was  noticed  immediately  after  the 
birth,  and  at  that  time  was  the  size  of  a  walnut.  It  contained  partly  clear,  amber- 
yellow,  somewhat  alkaline  fluid,  partly  a  thick,  honey-brown,  gelatinous  substance. 
The  tumor  lay  between  the  skin  and  the  rectus.  The  connective-tissue  wall  of  the 
cyst  contained  small,  thread-like,  cartilaginous  deposits,  and  the  cyst  was  lined 
with  simple  squamous  epithelium.  The  cyst  fluid  contained  fat,  cholesterin,  and 
numerous  cells.  The  possibility  that  this  was  a  dermoid  cyst  must  not  be  over- 
looked. 

For  umbilical  cysts  of  urachal  origin  see  pages  526  and  539. 

Co5'me,±  in  1909,  reported  a  case  that  hardly  belongs  to  the  solid  umbilical 
tumors,  and  yet,  on  the  other  hand,  cannot  be  considered  as  a  simple  umbilical  cyst. 

*  Caruso,  F.:  Contributo  alio  studio  anatomo-patologico  dei  tumori  cistici  dell'  ombelico. 
Atti  della  Soc.  Italiana  di  Ost.  e  Gin.,  1901,  viii,  293. 

fLedderhose:  Chirurgische  Erkrankungen  des  Xabels.  Deutsche  Chirurgie,  1890,  Lief. 
45  b. 

i  Coj'-ne:  Tumeur  congenitale  de  l'ombilic  developpee  dans  un  vestige  de  la  vesicule  allan- 
toidienne.  Comptes  rend,  nebdom.  des  seances  et  Mem.  de  la  Soc.  de  biol.,  Paris,  1909,  lxvii, 
383. 


480  THE    UMBILICUS    AND    ITS    DISEASES. 

Coyne's  tumor  was  from  a  woman  who  had  noticed  it  for  sixteen  months. 
She  had  always  had  some  abnormality  at  the  umbilicus.  The  mass  was  the  size 
of  an  adult's  head  and  was  pedunculated.  It  was  20  cm.  in  diameter.  On  section 
it  was  found  to  contain  arteries  and  veins  in  a  reticulated  tissue.  There  was  one 
large  cavity  with  three  or  four  secondary  cavities  opening  into  it.  These  contained 
vegetations. 

The  cavities  were  lined  with  cylindric  epithelium,  and  the  vegetation  was  cov- 
ered with  cylindric  epithelium.  In  the  pedicle  was  found  the  fibrous  tissue  char- 
acteristic of  the  urachus.  In  the  center  were  vestiges  of  the  allantois.  These 
portions  of  the  allantois  had  undergone  colloid  cystic  transformation  and  had  been 
the  point  of  departure  for  this  cystic  tumor. 

Whether  Coyne  was  right  in  his  assumption  I  am  not  in  a  position  to  judge. 


LITERATURE  CONSULTED  ON  UMBILICAL  HERNIA. 
Ahlfeld:  Zur  Aetiologie  der  Darmdefecte  und  der  Atresia  ani.     Arch.  f.  Gyn.,  1873,  v,  230. 
Brun:    Treatment  of  Umbilical  Hernia.  Jour.  Amer.  Med.  Assoc,  October  26,  1912,  1578.     Ab- 
stract from  Arch,  de  medecine  des  enfants,  Paris,  Sept.,  xv,  No.  9,  641. 
Caruso,  F. :   Contribute  alio  studio  anatomo-patologico  dei  tumori  cistici  dell'  ombelico.  Atti  della 

Soc.  Italiana  di  Ost.  e  Gin.,  1901,  viii,  293. 
Catteau,  J.  F.:    De  l'ombilic  et  de  ses  modifications  dans  les  cas  de  distension  de  l'abdomen. 

These  de  Paris,  1876,  obs.  11,  12,  13. 
Coyne:  Tumeur  congenitale  de  1'ombilic  developpee  dans  un  vestige  de  la  vesicule  allanto'idienne. 

Comptes  rend,  hebdom.  des  seances  et  Mem.  de  la  Soc.  de  biol.,  Paris,  1909,  lxvii,  383. 
Gallant,  A.  E. :  Disorders  of  the  Umbilicus  with  Special  Reference  to  the  New-born  and  the  Infant ; 

II;  Umbilical  Fistulas,  Sinuses,  and  Cysts.     International  Clinics,  1906,  16.  series,  iii,  218. 

See  also  International  Clinics,  1907,  17.  series,  i,  151. 
Gauderon:  De  la  peritonite  idiopathique  aigue  des  enfants;  de sa  terminaison  par  suppuration  et 

par  evacuation  du  pus  a  travers  l'ombilic     These  de  Paris,  1876,  No.  148. 
Kern,  Theo.:  Ueber  die  Divertikel  des  Darmkanals.     Inaug.  Diss.,  Tubingen,  1874. 
Ledderhose:    Deutsche  Chirurgie,  1890,  Lief.  45  b. 

Nicaise:  Ombilic.    Diet,  encyclopedique  des  sci.  med.,  Paris,  1881,  2.  ser.,  xv,  140. 
Perrin,  Maurice:  Brit.  Med.  Jour.,  April  9,  1910.     Epitome  of  Current  Med.  Lit.,  58. 
Power,  D'Arcy:    A  Case  of  Congenital  Umbilical  Hernia.     Trans.    Path.  Soc,  London,  1888, 

xxxix,  108. 
Reed,  Edward  N.:    Infant  Disemboweled   at   Birth — Appendectomy  Successful.     Jour.  Amer. 

Med.  Assoc,  July  19,  1913,  199. 
Runge,   M.:    Die  Wundinfectionskrankheiten  der  Neugeborenen.     Die  Krankheiten  der  ersten 

Lebenstage,  Stuttgart,  1893,  2.  Aufl.,  56. 
Sanderson,  S.  E.:  Personal  communication. 
Sheen,  William:    Some  Surgical  Aspects  of  Meckel's  Diverticulum.     Bristol  Medico-Chirurg. 

Jour.,  1901,  xix,  310. 
Stewart,  G.  C:  Hernia  of  the  Umbilical  Cord.     Brit.  Med.  Jour.,  1905,  i,  247. 
Wak,  Karl:    Ein  Beitrag  zur    Kenntnis    der    Nabelcysten.     Mtinch.  med.  Wochenschr.,  1902, 

xlix,  959. 
Yates,  H.  Wellington:   Personal  communication. 


CHAPTER  XXVIII. 
THE  URACHUS. 

General  consideration. 
Exstrophy  of  the  bladder. 

In  early  fetal  life  this  structure  passes  as  a  patent  duct  through  the  umbilicus, 
and  at  birth  in  a  few  cases  the  canal  still  persists.  A  consideration  of  the  umbilical 
portion  of  the  urachus  was  accordingly  essential.  The  subject  became  so  fascina- 
ting that  I  undertook  a  comprehensive  study  of  the  urachus  and  its  diseases,  the 
results  of  which  are  given  in  the  following  pages. 

In  the  chapter  on  Embryology,  the  development  of  the  urachus  is  given  in  full. 

Exstrophy  of  the  bladder  has  been  considered  here  because  clinically  it  has  some 
points  of  resemblance  to  the  dilated  umbilical  end  of  the  urachus  occasionally  noted: 

A  reference  to  the  chapter  on  The  Patent  Urachus  will  show  that  now  and  then 
the  urachus  remains  open  all  the  way  from  the  bladder  to  the  umbilicus,  and  that 
in  such  cases,  just  as  soon  as  the  cord  drops  off,  urine  escapes  both  from  the  urethra 
and  from  the  umbilicus. 

Under  remnants  of  the  urachus  I  have  considered  small  segments  of  the  duct 
that  have  persisted  in  children  or  in  adults.  Such  remnants  are  usually  spindle- 
shaped,  and  contain  a  small  amount  of  secretion,  which  may  be  yellow  and  limpid 
or  sticky  and  brownish  in  color. 

Urachal  cysts  form  a  very  interesting  group  of  cases.  They  may  be  small  or 
large.  The  small  ones  are  usually  not  larger  than  a  pea,  and  are  accidentally  dis- 
covered during  an  operation  or  at  autopsy.  The  large  cysts  occasionally  occupy 
not  only  the  entire  anterior  abdominal  wall,  but  also  the  pelvis.  They  naturally 
lie  between  the  abdominal  muscles  and  the  peritoneum  of  the  anterior  abdominal 
wall. 

Urachal  remains  occasionally  communicate  with  the  umbilicus  or  bladder  or 
with  both.  Those  opening  into  the  bladder  are  particularly  instructive.  These 
patients  usually  give  a  history  of  vesical  irritability,  and  from  time  to  time  pus  is 
passed  with  the  urine.  Sometimes  the  urachus  is  in  reality  an  alcove  from  the 
bladder,  the  opening  being  very  wide  and  assuring  complete  emptying  of  the  cavity 
each  time  the  bladder  is  evacuated.  On  the  other  hand,  if  the  communicating  open- 
ing is  very  small,  whenever  the  bladder  contracts,  a  good  deal  of  urine  may  be  forced 
into  the  urachal  pouch.  In  these  cases  the  urine  stagnates,  decomposes,  and  the 
patient  develops  a  train  of  constitutional  symptoms. 

From  time  to  time  a  very  hard  tumor  develops  between  the  umbilicus  and  pubes. 
This  usually  gives  the  patient  considerable  pain,  and  its  presence  is  sometimes 
accompanied  by  fever.  When  the  growth  is  exposed,  it  is  found  to  lie  between  the 
recti  muscles  in  front  and  the  peritoneum  of  the  anterior  abdominal  wall  behind. 
Its  walls  are  dense,  and  its  center  is  filled  with  grumous  material  mixed  with  pus. 
These  tumors  result  from  a  low-grade  infection  of  remnants  of  the  urachus. 
32  481 


482 


THE    UMBILICUS    AND    ITS    DISEASES. 


I  have  considered  acquired  urinary  fistulse  at  the  umbilicus  somewhat  fully. 
They  evidently  occur  only  rarely  unless  remnants  of  the  urachus  exist.  In  these 
cases  if  the  urethral  canal  is  closed  as  the  result  of  stricture,  an  enlarged  prostate, 
a  vesical  stone,  or  a  tumor  of  the  bladder  that  blocks  the  inner  urethral  orifice,  the 
old  path  from  the  bladder  to  the  umbilicus  may  become  open  again  and  the  urine 
escape  in  part  or  in  its  entirety  from  the  umbilicus,  until  the  urethral  obstruction  is 
removed. 

I  have  devoted  some  space  to  a  consideration  of  urachal  concretions  and  urinary 
calculi  associated  with  urachal  remains.     Urachal  calculi  may  be  multiple.     They 

are  very  small,  and  seem  in  the  main  to  be  composed 
of  inspissated  contents  of  the  small  cyst  cavities. 
Urinary  calculi  are  now  and  then  associated  with 
urachal  remains,  and  in  one  instance  at  least  a  vesi- 
cal stone  has  been  removed  through  the  umbilicus. 
In  this  case  the  urachus  extended  as  a  wide  canal 
from  the  umbilicus  to  the  bladder. 

In  a  few  cases  malignant  changes  have  developed 
in  a  patent  urachus.  The  growth  may  be  a  cancer 
or  a  sarcoma. 

With  the  careful  study  and  publication  of  urachal 
lesions  in  the  future,  I  feel  sure  other  interesting  ura- 
chal remnants  or  pathologic  conditions  caused  by 
them  will  be  brought  to  light. 


EXSTROPHY  OF  THE  BLADDER. 

An  extended  description  of  exstrophy  of  the  blad- 
der hardly  comes  within  the  scope  of  this  book,  but, 
on  account  of  its  occasional  proximity  to  the  um- 
bilicus, I  shall  briefly  consider  it. 

A  glance  at  the  chapter  on  Embiyology  (p.  17) 
will  show  that  the  bladder  in  the  young  embryo 
frequently  extends  upward  almost  to  the  umbilicus ; 
consequently,  if  for  any  reason  there  be  a  defect  in 
the  lower  abdominal  wall,  exstrophy  of  the  bladder 
may  result. 

Prestat,*  in  1838,  described  the  appearance  of  a 


Fig.  207. — Exstrophy  of  the  Blad- 
der. (After  F.  A.  von  Amnion.) 
(Plate  16.  Fig.  16.  Copied  from 
Froriep.)  This  shows  the  bladder  open- 
ing at  or  near  the  umbilicus.  The  geni- 
tal structures  appear  to  be  normal,  and 
the  abdominal  wall  immediately  above 
the  symphysis  is  unaltered,  a,  The 
bladder  opening  very  high  up;  6,  the 
surrounding  undulatingabdominal  wall. 


still-born  child  at  the  seventh  month,  with  exstrophy 
of  the  bladder.  The  greater  portion  was  open  anteriorly.  The  bladder  was  repre- 
sented as  a  slight  depression  covered  over  with  mucous  membrane,  which  was  con- 
tinuous with  the  skin  of  the  abdomen.  It  extended  from  half  an  inch  below  the 
umbilicus  to  the  pubes.  In  its  lower  part  were  two  tubercles — the  ureteral  open- 
ings. The  pubic  bones  were  represented  by  fibrous  tissue.  The  other  pelvic  struc- 
tures were  normal. 

Yon  Amnion,!  in  his  book  on  Congenital  Surgical  Diseases,  published  in  1842, 


1842. 


*  Prestat:  Bull,  de  la  Soc.  anat.  de  Paris,  1838-39,  xiii,  69. 

t von  Amnion,  F.  A.:    Die  angeborenen  chirurgischen  Krankheiten  des  Menschen,  Berlin, 


THE    URACHUS. 


483 


says  that  the  umbilicus  in   cases  of    exstrophy  of  the  bladder  is  inserted  very 

deeply. 

He  refers  to  an  interesting  case  of  bladder  exstrophy  reported  by  Froriep.     The 

illustrations  in  this  case  are  most  instructive. 

Fig.   207    shows    a    large,   almost    circular    opening    in  the    umbilical  region. 

Through  this  aperture  the  posterior 
wall  of  the  bladder  is  visible.  The 
lower  part  of  the  anterior  abdom- 
inal wall  is  intact  and  the  genitals 
of  the  child,  which  was  a  male,  are 
normal. 

In  Fig.  208  we  have  a  lateral 
view  of  the  entire  urinary  tract. 
The  only  abnormality  is  in  the 
upper   part   of    the   bladder.     The 

nt 


¥#  '"lite  ml 


Fig.  208. — Exstrophy  of  the  Bladder.  (After  F.  A.  von 
Ammon.) 
This  is  a  side  view  of  the  case  depicted  in  Fig.  207,  and 
gives  the  relative  distance  from  the  symphysis  to  the  opening 
in  the  abdominal  wall,  a,  the  opening;  6,  6,  the  margins; 
d,  the  bladder;  g,  the  covering  and  peritoneum  of  the  posterior 
surface;  h,  the  ureter;  h',  the  kidney. 


Fig.  209. — Exstrophy  of  the  Bladder.  (After 
von  Ammon.) 
This  represents  Fig.  207  turned  inside  out.  The 
bladder  has  literally  been  inverted  upon  the  abdo- 
men, a,  the  bladder  mucosa;  d,  d,  are  a  short  dis- 
tance from  the  corresponding  ureteral  orifice;  6,  b, 
indicate  the  margins  of  the  opening. 


top  of  the  bladder  is  firmly  fixed  to,  and  opens  directly  upon,  the  abdominal  wall, 
just  below  where  the  umbilicus  should  be. 

Fig.  209  shows  that  it  was  possible  for  almost  the  entire  bladder  to  prolapse 
through  the  exstrophy  opening.  In  other  words,  the  bladder  could  be  turned  in- 
side out,  and  the  ureteral  orifices  were  then  recognized  as  small  openings  just 
above  the  symphysis.     Such  a  picture  as  this  is,  of  course,  exceptional. 


484  THE    UMBILICUS    AND    ITS    DISEASES. 

Exstrophy  of  the  Bladder.  —  Recently  a  very  interesting  case 
of  this  character  came  under  our  observation: 

Gyn.  No.  21594.  Miss  A.  C.  H.,  aged  twenty-nine,  was  admitted  to  the  Gyne- 
cological Department  of  the  Johns  Hopkins  Hospital  under  Dr.  Howard  A. 
Kelly's  care  on  October  11,  1915,  for  a  "  growth  in  the  abdominal  wall." 

Her  father,  mother,  one  sister,  and  two  brothers  are  living  and  well,  and  she 
has  always  enjoyed  relatively  good  health.  No  history  of  congenital  malformation 
in  any  member  of  the  family  could  be  elicited. 

The  patient  began  to  menstruate  at  seventeen,  was  irregular  for  five  years, 
but  has  been  regular  since  then.  The  flow  lasts  six  days  and  is  accompanied  by 
pain  on  the  first  day.     There  is  no  intermenstrual  bleeding. 

Present  Illness. — The  patient  has  always  had  a  mass  in  the  lower  abdominal 
wall.  She  does  not  think  it  has  grown  except  in  proportion  to  the  growth  of  the 
body.  The  pubic  bones  have  always  been  widely  separated,  as  they  are  now, 
causing  nodular  elevations  laterally.  There  is  no  difficulty  in  walking.  The 
patient  has  never  been  very  strong,  but  has  always  been  well. 

Her  main  discomfort  has  been  a  tenderness  in  the  lower  border  of  this  mass, 
accompanied  by  an  inability  to  hold  her  urine.  She  has  always  worn  pads  to 
catch  it.  The  urine  has  never  showed  blood.  The  mass  has  not  ulcerated,  but 
slight  traumatism  has  always  been  sufficient  to  start  bleeding. 

When  the  patient  was  fifteen,  she  had  pain  in  the  left  side,  the  maximal  intensity 
being  in  the  upper  left  fossa.  There  was  also  great  tenderness  in  the  left  superior 
lumbar  triangle.  The  pain  was  intermittent;  it  was  unaccompanied  by  nausea 
or  vomiting,  and  was  not  sufficient  to  cause  the  patient  to  go  to  bed.  These  pains 
lasted  for  two  years.  Since  then  they  have  occurred  once  or  twice  a  year,  but  have 
been  relieved  by  hot  applications.  Ever  since  the  trouble  on  the  left  side  the  urine 
from  the  left  ureter  has  been  cloudy  and  scant  in  amount.  The  flow  from  the  right, 
on  the  other  hand,  has  always  been  abundant. 

Physical  Examination. — The  right  kidney  extends  to  the  crest  of  the  ilium,  the 
left  cannot  be  felt.  The  umbilicus  is  small,  shallow,  and  situated  rather  low  in  the 
abdominal  wall. 

In  the  mid-line,  in  the  suprapubic  region,  is  a  red,  raw-looking  mass,  which 
is  soft  and  contains  urine  (Plate  VII).  It  looks  something  like  a  large  red  rasp- 
berry, with  lobulations  at  irregular  intervals  on  its  surface.  On  its  inferior  surface 
are  two  lobulated  knobs.     At  the  apex  of  each  knob  is  a  small  orifice.     From  the 


Plate  VII. 
Exstrophy  of  the  Bladder. 

The  patient  was  twenty-nine  years  old.  The  inverted  bladder  is  seen  situated  where  the  symphysis  pubis  should 
be.  Its  velvety  mucous  surface  is  rolled  out  and  hangs  over  the  labia  minora.  The  prominence  on  each  side  repre- 
sents the  pubic  ramus.  Between  them  is  a  gap  7  cm.  wide,  which  is  bridged  over  by  a  strong  fibrous  band.  Between 
the  umbilicus  and  the  exstrophied  bladder  is  a  flattened,  triangular  area,  bordered  on  its  sides  by  the  separated  recti 
muscles,  which  are  inserted  into  their  respective  separated  pubic  bones.  The  triangle  is  divided  perpendicularly  by 
a  thick,  cord-like  structure  connecting  the  umbilicus  and  bladder — evidently  the  urachus.  Where  exstrophy  of  the 
bladder  exists,  the  umbilicus  is  usually  much  nearer  the  symphysis.  In  this  case,  however,  it  is  not  far  below  its  normal 
position. 

In  the  upper  left  diagram  the  bladder  has  been  gently  raised,  exposing  the  ureteral  orifices.  Urine  escaped  freely 
from  the  right  ureter;   the  left  was  apparently  functionless. 

The  labia  minora  arc  widely  separated  above.     The  clitoris  apparently  consists  of  two  separated  portions. 

The  right  upper  picture  schematically  represents  the  abdominal  topography.  Note  the  wide  separation  of  the 
pubic  bones  and  of  the  anterior-superior  spines,  likewise  the  unusually  wide  space  between  the  thighs. 


THE    TJKACHUS. 


485 


PLATE  VII. 
Exstrophy  of  the  Bladder. 


X 


X 


\ 


486  THE    UMBILICUS    AND    ITS    DISEASES. 

right,  urine  flows  in  a  small  stream  on  voluntary  expulsion  by  the  patient.  The 
lower  and  under  surface  of  the  mass  is  very  tender.  The  mass  measures  4.5  x  3  x  4 
cm.     It  cannot  be  reduced  into  the  abdomen. 

The  pubic  hairs  are  scanty.  The  labia  minora  are  very  atrophic,  and  diverge 
above,  extending  outward  to  the  lateral  margins  of  the  exstrophy.  Some  observers 
are  of  the  opinion  that  the  clitoris  is  absent;  others  that  it  appears  as  two  rudi- 
mentary portions.  The  urethra  and  the  anterior  bladder-wall  are  totally  wanting. 
The  vaginal  orifice  is  very  small;   the  hymen  is  intact. 

Rectal  Examination. — The  sphincter  tone  is  normal.  The  cervix  is  elongated, 
and  its  external  os  lies  just  within  the  hymen.  The  uterus  is  somewhat  enlarged 
and  in  good  position.  The  adnexa  cannot  be  felt.  From  each  uterine  cornu  a 
round  cord,  the  size  of  a  lead-pencil,  can  be  felt  passing  downward  and  outward  to 
the  inguinal  canal — these  are  apparently  the  round  ligaments. 

At  the  apex  of  the  vagina,  and  extending  laterally  from  the  junction  of  the 
cervix  and  body  of  the  uterus,  firm,  ligamentous  structures  can  be  palpated — 
these  are  probably  the  bases  of  the  broad  ligaments. 

A  cord  can  be  felt  extending  from  the  upper  margin  of  the  exstrophied  bladder 
to  the  umbilicus.     This,  undoubtedly,  is  the  urachus. 

The  pelvis  has  a  peculiar  form.  It  is  abnormally  wide;  it  shows  a  flaring  of  the 
false  pelvis  and  a  wide  diastasis  of  the  anterior  pelvic  arch.  The  spines  of  the 
pubes  are  19  cm.  apart.  For  a  woman  of  her  size  they  should  be  10  cm.  apart. 
The  mesial  borders  of  the  pubic  bones  are  separated  by  a  space  of  7  cm.,  there  being 
a  tight,  dense,  but  pliable  ligament  connecting  them. 

The  following  are  the  measurements  of  the  pelvis : 

Distance  between  the  pubic  bones  in  front 7  cm. 

Distance  between  the  external  superior  spines 19  cm. 

Distance  between  the  anterior  superior  spines  of  the  ilium 32.5  cm. 

Distance  between  the  iliac  crests 35  cm. 

Distance  between  the  great  trochanters 39  cm. 

The  perineum  is  wide.  When  the  legs  are  brought  together,  the  space  between 
them  is  not  closed.  With  the  knees  together  and  the  legs  flexed,  there  is  a  space 
9  cm.  broad,  representing  the  width  of  the  perineum. 

A  glance  at  Plate  VII  will  give  the  reader  a  clear  idea  of  the  appearance  of  the 
exstrophy. 

The  implantation  of  the  ureters  into  the  rectum  was  considered,  but  the  pa- 
tient refused  to  have  anything  done  and  returned  to  her  home. 

Kelly  and  Burnam,*  when  referring  to  the  subject  of  exstrophy  of  the  bladder, 
quote  Spooner  as  saying  that  in  116,500  patients  it  was  noted  only  four  times,  a 
clear  indication  that  this  is  a  very  rare  malformation.  In  Fig.  491,  Vol.  II,  of  Kelly 
and  Burnam's  work,  is  depicted  an  exstrophy  of  the  bladder  observed  by  Guy  L. 
Hunner.  In  this  case  the  exstrophy  bears  a  marked  resemblance  to  the  one  we 
are  describing,  but  the  umbilicus  was  situated  just  above  the  exstrophy,  instead 
of  in  the  relatively  normal  position. 

*  Kelly,  Howard,  and  Burnam,  Curtis  F. :  Diseases  of  the  Kidneys,  Ureters,  and  Bladder, 
I).  Appleton  &  Co.,  1914,  ii,  385. 


CHAPTER  XXIX. 

CONGENITAL  PATENT  URACHUS. 

Symptoms. 

Appearance  of  the  umbilicus. 

An  umbilicus  without  tumor  formation. 

An  umbilicus  with  tumor  formation. 
Treatment. 

Patent  urachus  and  patent  omphalomesenteric  duct  in  the  same  child. 
Detailed  report  of  cases  of  children  born  with  a  patent  urachus. 

Occasionally  an  infant  is  brought  to  the  physician  with  the  history  that  a 
few  days  after  birth  a  watery  discharge  was  noted  at  the  umbilicus  and  that  this 
discharge  has  continued.  Where  the  discharge  is  abundant,  it  is  invariably  due  to 
a  patent  urachus. 

Escape  of  Urine.  —  The  manner  in  which  the  urine  escapes  from  the 
umbilicus  varies.  It  may  come  away  in  very  small  quantities  or  be  discharged  in 
abundance.  In  Jacoby's  case  the  umbilical  depression  was  often  filled  with  urine. 
In  Goupil's  case  it  came  drop  by  drop,  as  from  a  still.  In  Alric's  Case  1  it  came  drop 
by  drop  when  the  child  cried.  In  Charles'  case  urine  would  "fall"  from  the  umbili- 
cus. In  Jahn's  case  urine  escaped  when  pressure  was  made  upon  the  abdomen. 
Stierlin's  patient  passed  only  a  small  quantity  from  the  umbilicus  during  the  day, 
but  at  night  the  bed  was  saturated.  In  Paget's  case  the  urine  gushed  from  the 
umbilicus,  while  in  Marx's  case  it  came  away  in  jets.  French's  patient  dis- 
charged a  small  umbilical  stream  when  crying.  Annandale's  patient,  who  was 
thirty-nine  years  of  age,  passed  two-thirds  of  his  urine  from  the  umbilicus  in  a 
stream,  when  in  the  upright  position;  when  he  was  lying  down,  the  urine  escaped 
involuntarily  from  the  umbilicus.  Erdmann's  patient,  who  was  four  years  old,  at 
times  passed  an  umbilical  stream  4  to  12  inches  high.  In  Hue's  case  the  urine 
escaped  from  the  umbilicus  at  night. 

In  Pauchet's  case  the  escape  of  urine  from  the  umbilicus  was  intermittent, 
occurring  at  intervals  of  from  four  to  five  days  and  persisting  from  one  to  two  days 
each  time. 

In  Cabrol's  case,  in  which  the  urethra  was  completely  blocked,  all  the  urine, 
of  course,  escaped  from  the  umbilicus. 

The  character  and  size  of  the  umbilical  stream  will,  of  course,  depend  on  the 
caliber  of  the  patent  urachus,  the  size  of  the  umbilical  opening,  and  occasionally 
on  the  ease  or  difficulty  with  which  urine  can  escape  from  the  urethra.  The  urine 
naturally  follows  the  path  of  least  resistance. 

On  questioning  the  parent  it  will  be  found  that  the  urine  commenced  to  escape 
from  the  umbilicus  just  after  the  cord  came  away;  and  some  of  the  more  careful 
observers  among  the  physicians,  midwives,  and  mothers  will  have  noted  that  the 
umbilical  cord  was  unusually  thick  near  the  abdomen.  In  these  cases,  of  course, 
the  urachus  was  patent  from  the  bladder  to  a  point  in  the  cord  distal  from 

487 


488 


THE    UMBILICUS    AND    ITS    DISEASES. 


the  point  of  ligation,  and  naturally  no  urine  could  escape  until  the  ligature  had 
sloughed  off. 

In  Delageniere's  case  the  urachus  was  evidently  almost  patent  at  birth,  but  did 
not  open  until  the  child  was  six  months  old. 


Membranous 
veil  at  internal 
urethral  orifice 


APPEARANCE  OF  THE  UMBILICUS. 
In  glancing  over  the  detailed  histories  of  the  cases  of  patent  urachus  it  will  be 
noted  that  in  some  cases  the  umbilicus  was  but  little  altered  (Fig.  210),  while  in 

others  a  definite,  tumor-like  mass 
was  found. 

An  Umbilicus  Without 
Tumor  Formation.  —  The 
umbilicus  may  show  little  deviation 
from  the  normal,  and  the  urachal 
opening  be  scarcely  visible.  In  other 
cases  the  umbilicus  is  a  little  broader 
than  usual  and  has  five  or  six  radial 
folds.  At  the  place  where  these  meet 
the  urachal  opening  is  usually  found, 
and  sometimes  there  is  a  definite 
funnel-like  depression.  Occasion- 
ally, as  noted  in  Huggins'  case,  the 
urachal  opening  may  be  found  in  the 
lower  margin  of  the  umbilical  ring. 
In  Stevens'  case  there  was  a  small 
hernial  protrusion  at  the  umbilicus. 
Fig.  255  (p.  625)  represents  a  small 
hernial  protrusion  associated  with 
a  patent  urachus. 

An  Umbilicus  with 
Tumor  Formation.  —  As 
a  rule,  the  umbilical  growth  is  small. 
Sometimes  it  is  very  minute,  as  in 
Florentin's  case,  in  which  it  was  the  size  of  a  pea.  The  nodule  is  usually  spoken  of 
as  being  the  size  of  a  nut,  a  cherry,  or  small  strawberry.  Sometimes  it  is  dark 
red,  flabby,  and  suggests  granulation  tissue.  In  other  cases  it  may  be  firm,  and  red 
or  violet  in  color.  In  a  few  cases  it  resembled  a  mushroom  or  flattened  button, 
and  was  attached  to  the  umbilicus  by  a  pedicle  (Fig.  211). 

In  Starr's  case  the  umbilicus  was  larger  and  more  widely  open  than  usual,  and  in 
the  center  of  the  cartilaginous,  nipple-like  projection  was  an  orifice  which  admitted 
an  ordinary  probe.  In  Cabrol's  case  (quoted  by  Florentin)  there  was  a  projection 
at  least  four  fingerbreadths  long  which  resembled  the  crest  of  a  turkey.  In  Alric's 
Case  1,  a  boy  ten  months  old,  had  a  bright-red  umbilical  projection,  3  or  4  cm.  long. 
This  also  bore  a  marked  resemblance  to  the  comb  of  a  turkey-gobbler. 

Occasionally  the  umbilical  tumor  resembled  a  glans  penis  (Fig.  212).  Meyer's 
patient  was  a  child  one  year  old.  The  umbilicus  was  thickened  and,  although  no 
hernia  existed,  it  was  prominent  and  in  contour  resembled  a  glans  penis. 


Fig.  210. — Escape  of  Urine  from  the  Umbilicus  When 
the  Inner  Urethral  Orifice  is  Blocked  by  a  Mem- 
brane.    (Schematic.) 

At  least  one  case  of  this  character  has  been  recorded.  As 
soon  as  the  membrane  was  severed,  nearly  all  the  urine  es- 
caped by  the  urethra,  and  in  a  short  time  the  discharge  from 
the  umbilicus  ceased. 


CONGENITAL  PATENT  URACHUS. 


489 


Fig.  211. — A  Patent  Urachus  tvith  a  Mushroom-like 
Projection  at  the  Umbilicus.      (Schematic.) 


French's  patient  was  a  female  infant 
six  weeks  old.  At  the  umbilicus  there 
was  a  hernia-like  protrusion  of  the  skin 
about  three-quarters  of  an  inch  in 
length,  surmounted  by  a  red,  fleshy 
outgrowth  like  a  swollen  and  fungoid 
glans  penis;  whenever  the  child  cried 
or  struggled,  this  growth  became  very 
prominent  and  vascular.  In  practic- 
ally all  of  the  cases  in  which  the  um- 
bilical tumor  existed,  the  urachal  open- 
ing was  situated  in  the  center  of  its 
most  prominent  point. 

Size  of  the  Umbilical 
Opening.  —  Sometimes  it  is  not 
larger  than  a  pin-point  and  is  hardly 
demonstrable.  In  other  cases  it  is  one 
or  more  millimeters  in  diameter,  and 
may  admit  a  fine  probe  or  a  medium- 
sized  catheter.  Sometimes  the  probe 
or  catheter  can  be  carried  from  the  um- 
bilicus directly  into  the  bladder,  and,  if  the  bladder  extends  almost  to  the  umbilicus, 
the  distal  end  of  the  probe  can  be  swung  as  a  pendulum  from  side  to  side.     In  some 

cases,  particularly  in  those  in 
which  the  urachus  is  tortuous, 
the  probe  can  be  passed  only  a 
short  distance. 

Irritation.  —  Occasion- 
ally there  is  a  mild  or  severe  in- 
flammation of  the  skin  around  the 
umbilicus,  the  degree  evidently 
depending  on  the  irritating  quali- 
ties of  the  escaping  urine.  At 
times  the  inflammation  of  the 
skin  may  be  so  severe  that  small 
ulcerations  develop. 

In  Hind's  case,  in  a  very  young 
infant  extravasation  of  urine  oc- 
curred around  the  umbilicus  and 
finally  extended  all  over  the  ab- 
domen.    The  child  soon  died. 

Sex.  —  In  53  of  the  cases 
here  recorded,  35  of  the  patients 
were  males  and  18  females.  These 
figures  seem  to  coincide  with  those 
of  other  observers  in  showing  that 
a  patent  urachus  at  birth  is  more 
common  in  males  than  in  females. 


Fig.  212. — A  Patent  Urachus  tvtth  a  Penile  Projection  at 
the  Umbilicus.  (Schematic.) 
Where  the  urachus  remains  patent  the  umbilical  end  may  ap- 
pear as  a  small  depression  in  the  floor  of  the  umbilicus.  In  some 
instances  a  mushroom-like  elevation  occupies  the  site  of  the  um- 
bilicus. In  exceptional  cases  a  definite  penile  projection  springs 
from  the  umbilicus,  and  at  the  end  of  this  is  the  opening  of  the 
urachus,  as  indicated  in  the  picture. 


490  THE    UMBILICUS    AND    ITS    DISEASES. 

Monod,  in  his  splendid  monograph,  says  that  it  is  three  times  more  common  in 
males  than  in  females. 

Race.  —  It  will  be  noted  that  both  Cabell's  and  Stites'  patients  were  colored. 
Future  observations  will  probably  demonstrate  that  a  patent  urachus  is  relatively 
as  common  in  the  colored  as  in  the  white  races.  The  majority  of  our  observations 
to  date  have  come  from  countries  and  localities  where  few  negroes  are  found. 

General  Condition  of  the  Child.  — -  From  the  histories  it  will 
be  seen  that  nearly  all  the  children  were  in  good  health.  A  few  were  anemic  or 
slightly  emaciated,  but  no  greater  percentage  than  one  would  expect  to  find  under 
ordinary  conditions.  The  presence  of  a  patent  urachus  seems  to  have  little  effect 
on  the  general  health  of  the  child. 

TREATMENT. 

Before  undertaking  the  closure  of  the  umbilical  fistula  the  patency  of  the  urethra 
must  first  be  ascertained.  In  the  majority  of  the  cases  the  urethra  has  been  per- 
fectly normal.  In  some  cases,  however,  a  phimosis  exists,  and  under  these  a  cir- 
cumcision should  first  be  performed. 

Goupil,  in  1756,  reported  the  case  of  a  twelve-year-old  boy  all  of  whose  urine 
escaped  from  the  umbilicus.  In  this  case  there  was  a  congenital  malformation  and 
the  penis  was  not  perforated.  Draudt  reports  a  case  of  urinary  umbilical  fistula 
in  a  child  a  day  old.  Death  occurred  on  the  fifteenth  day,  and  at  autopsy  it  was 
found  that  the  urethra  was  almost  totally  obliterated.  It  is  obvious  that  in  Goupil's 
and  in  Draudt's  case  any  attempt  to  close  the  umbilical  fistula  would  not  only  have 
been  useless,  but  essentially  harmful. 

Quite  a  number  of  the  patients  were  never  operated  upon,  and  the  urinary 
umbilical  fistula  persisted  even  in  adult  life.  Spontaneous  closure  of  the  fistula  is 
exceptional.  Lugeol,  however,  reports  the  case  of  a  female  child  who  had  at  the 
umbilicus  a  small,  soft,  reddish- violet  tumor,  in  the  center  of  which  was  a  small 
fistulous  opening.  Little  by  little  the  urinary  discharge  from  this  diminished  and 
finally  disappeared.     Five  months  later  the  child  was  well. 

Tuholske  also  reports  a  case  of  spontaneous  healing.  His  patient  was  a  man 
fifty-two  years  of  age.  In  infancy  he  had  passed  urine  from  the  umbilicus.  This 
condition  ceased  in  his  fourth  year  without  treatment,  and  he  had  no  further  trouble 
until  his  forty-eighth  year,  when,  apparently  without  cause,  the  urine  again  com- 
menced to  flow  through  the  navel. 

Monod  reports  the  case  of  a  patient  that  came  under  the  care  of  Jaboulay.  A 
man  sixty-two  years  of  age,  who  was  suffering  with  painful  micturition  and  symp- 
toms of  an  enlarged  prostate,  noticed  urine  escaping  from  the  umbilicus.  When 
questioned,  he  said  that  his  mother  had  often  told  him  that  shortly  after  birth  he 
was  treated  for  the  escape  of  urine  from  the  umbilicus,  and  that  this  discharge  had 
disappeared  in  the  course  of  fifteen  days  after  the  application  of  an  appropriate 
bandage.     Jaboulay's  case  is  another  example  of  spontaneous  closure  of  the  fistula. 

In  the  early  days  the  fistulous  opening  was  usually  treated  with  caustics  or  with 
the  actual  cautery,  and  in  quite  a  number  of  instances  the  fistula  soon  closed. 
( Occasionally  a  simple  plastic  operation  gave  very  fair  results. 

In  those  cases  in  which  a  definite  umbilical  tumor  was  present,  it  was  in  some 
instances  transfixed  with  needles  and  ligated.  The  tumor  would  slough  off  in  a  few 
days,  and  the  umbilical  end  of  the  fistulous  tract  usually  remained  closed. 


CONGENITAL  PATENT  URACHUS-  491 

Where  the  urachus  still  persists,  there  is  always  a  chance  of  subsequent  trouble, 
and  there  are  at  least  three  cases  on  record  in  which  the  patient  later  developed  cancer 
of  the  urachus.  Graf  reported  the  case  of  a  man,  twenty-eight  years  old,  who  died 
of  cancer  of  the  urachus.  This  patient  at  birth  had  an  umbilical  fistula.  It  was 
healed  with  escharotics.  Twenty-five  years  later  carcinoma  of  the  urachus  devel- 
oped. Hoffmann  also  reports  a  case  in  which  the  patent  urachus  was  closed  with 
escharotics  when  the  child  was  in  his  third  year.  This  man,  when  twenty-seven 
years  old,  developed  a  fatal  carcinoma  of  the  urachus. 

Fischer  records  the  case  of  a  man  of  thirty-two  who  had  an  inoperable  carci- 
noma of  the  urachus.  During  childhood  this  man,  when  voiding,  had  been  aware 
of  a  "moisture  at  the  umbilicus."  Later  this  symptom  had  disappeared  and  he 
had  noticed  no  further  trouble  until  he  was  thirty-one  years  old. 

In  the  light  of  our  present  knowledge  of  abdominal  surgery  the  wise  plan  is 
always  to  remove  the  fistulous  tract.  The  umbilicus  is  encircled  and  freed,  and, 
together  with  the  fistulous  tract,  is  dissected  free  to  the  bladder.  The  bladder 
attachment  of  the  urachus  is  treated  in  precisely  the  same  manner  that  an  appendix 
stump  is  dealt  with,  namely,  by  the  employment  of  a  purse-string  suture.  After  the 
stump  has  been  inverted  into  the  bladder,  the  closure  is  reinforced  with  one  or  two 
more  sutures  and  the  wound  closed.  The  purse-string  suture  should  consist  of  fine 
black  silk  or  of  catgut  that  will  last  for  several  weeks.  This  method  of  treatment 
has  been  in  use  for  several  years,  and  has  yielded  excellent  immediate  results.  It 
has  also  insured  absolutely  against  any  subsequent  urachal  trouble. 

In  those  cases  in  which  the  urachus  gradually  broadens  out  into  the  bladder,  the 
bladder  opening  is  naturally  large  and  sometimes  cannot  be  satisfactorily  closed 
with  a  purse-string  suture.  In  such  cases  it  may  be  necessary  to  close  it  with  a 
continuous  suture,  as  in  the  procedure  for  closing  the  bladder  after  a  suprapubic 
operation. 


PATENT  URACHUS  AND  PATENT  OMPHALOMESENTERIC  DUCT  IN  THE  SAME  CHILD. 

We  have  found  numerous  examples  of  a  patent  omphalomesenteric  duct  and  of 
a  patent  urachus,  but  there  are  only  two  cases,  as  far  as  we  could  learn,  in  which 
both  were  patent  in  the  same  child. 

Lexer,  in  his  article  on  the  Treatment  of  Urachal  Fistulas,  refers  to  the  case  of  a 
boy  a  year  old.  Urine  escaped  in  large  quantities  from  the  umbilicus.  From  the 
accompanying  history  it  is  certain  that  at  operation  a  patent  omphalomesenteric 
duct  was  found,  in  that  it  is  stated  that  the  fistula  was  lined  with  typical  intestinal 
mucosa.  There  seems  to  be  little  doubt  that  both  the  vitelline  duct  and  the  urachus 
were  patent. 

In  the  second  case — related  to  me  by  Dr.  Heflin — at  operation  a  fistulous  tract 
passing  directly  from  the  umbilicus  to  the  small  bowel  was  found.  This  tract  was 
three  inches  long.  After  it  had  been  cut  away  and  the  bowel  closed,  a  second  tube 
was  found  extending  from  the  umbilicus  to  the  bladder.     This  was  also  patent. 

I  have  had  microscopic  sections  made  from  this  case.  One  duct,  the  vitelline, 
is  lined  with  typical  intestinal  mucosa,  the  other,  the  urachus,  with  remnants  of 
transitional  epithelium.  The  patency  of  both  ducts  in  this  case  cannot  be  ques- 
tioned (Fig.  214). 

Both  of  these  cases  are  of  such  interest  that  I  wall  cite  them  in  detail. 


492  THE    UMBILICUS    AND    ITS    DISEASES. 

A  Patent  Urachus  and  Probably  a  Patent  Omphalo- 
mesenteric Duct.  —  Lexer*  in  his  article  reports  the  case  of  a  boy,  a 
year  and  a  half  old.  The  cord  came  away  on  the  fifth  day  and  clear  fluid  was 
noticed  coming  from  the  umbilicus.  It  is  said  that  at  this  time  there  was  a  reddish 
tumor,  the  size  of  the  end  of  the  little  finger,  at  the  umbilicus.  This  gradually 
became  smaller  and  finally  disappeared.  When  the  child  was  six  months  old  the 
fistula  was  closed  by  a  physician  by  means  of  salves  and  plasters.  It  remained 
closed,  however,  for  only  two  weeks.  The  child  was  restless,  and  there  were  general 
systemic  disturbances.  When  the  fistula  reopened,  a  large  quantity  of  watery  fluid 
escaped,  and  pus  was  said  to  have  come  away  at  one  time.  Wnen  Lexer  saw  the 
child  he  was  somewhat  weak  and  pale.  About  5  mm.  below  the  umbilicus  was  a 
fistulous  opening  surrounded  by  an  area  of  inflammation.  Each  time  the  child 
urinated  a  large  quantity  of  urine  escaped  from  the  fistula,  whereas  from  the  urethra 
it  passed  drop  by  drop.  There  was  a  marked  congenital  phimosis.  The  case  was 
diagnosed  as  one  of  urachal  fistula.  By  placing  a  glass  at  the  umbilicus  the  ob- 
server estimated  that  about  one-quarter  to  one-third  of  the  urine  escaped  from  the 
navel.  With  a  sound  it  was  possible  to  make  out  only  a  small,  bay-like  cavity 
beneath  the  skin. 

The  prepuce  was  cut;  four  weeks  later  the  urine  was  flowing  normally  and 
there  had  been  a  diminution  in  the  size  of  the  fistula.  After  excision  of  the  skin 
around  the  umbilicus  there  was  disclosed  a  depression  lined  with  granulations,  and 
scarcely  larger  than  a  hazelnut,  communicating  with  the  fistula.  From  this  fistu- 
lous opening  a  sound  could  be  passed  exactly  in  the  mid-line  of  the  abdomen  toward 
the  bladder  region.  Further  examination  could  not  be  made,  as  the  child  did  not 
take  the  anesthetic  well.  As  the  mucosa  of  the  fistulous  tract  was  exposed,  it  was 
grasped  with  forceps  and  gradually  drawn  out.  The  sac  was  dissected  out  and  the 
wound  closed. 

The  tube  was  7  cm.  long,  and  microscopic  examination  showed  that  it  was  not  a 
patent  urachus,  but  a  persistent  omphalomesenteric  duct.  This  on  cross-section 
showed  a  well-developed  intestinal  mucosa;  the  lumen  increased  in  size  as  it  passed 
inward.  It  was  lined  with  cylindric  epithelium,  had  the  typical  Lieberkiihn's 
glands,  and  also  the  circular  and  longitudinal  muscle-fibers.  Lexer  said  that  from 
the  above  picture  it  was  clear  that  he  was  dealing  with  a  Meckel's  diverticulum. 
The  child  remained  well. 

The  history  clearly  demonstrates  the  existence  of  a  urinary  fistula,  and  the 
microscopic  examination  of  the  specimen  shows  a  tube  lined  with  intestinal  mucosa. 
The  only  way  in  which  the  picture  can  be  adequately  explained  is  by  a  persistence 
of  both  the  urachus  and  the  omphalomesenteric  duct. 

A  Patent  Urachus  and  a  Patent  Omphalomesenteric 
Duct  in  the  Same  Child.  —  Wliile  conversing  with  Dr.  H.  T.  Heflin,  of 
Birmingham,  Ala.,  on  May  6,  1912,  he  related  to  Dr.  Cunningham  Wilson 
and  myself  his  experience  with  a  child  fourteen  months  old.  He  saw  the  patient 
(J.  S.J  on  August  29,  1911.  Two  or  three  days  after  birth  bleeding  occurred  from 
the  umbilicus.  This  bleeding  at  times  was  moderate  in  amount,  but  at  other  times 
severe,  and  as  a  result  the  child  became  very  anemic.  Apart  from  this  he  was 
perfectly  well  except  for  a  tight  prepuce,  which  had  to  be  released.  He  was  often 
constipated  and  cried  a  great  deal.  The  more  he  cried  the  more  he  bled.  Dr. 
*  Lexer,  E.:  Ueber  die  Behandlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  1898,  lvii,  73. 


CONGENITAL  PATENT  URACHUS. 


493 


Fig.  213. — The  Appearance  of  the  Umbilicus  in  a  Case  in  Which  Both  a  Patent  Omphalomesenteric  Duct 
and  a  Patent  Urachus  Existed.  (Heflin's  case.) 
The  umbilical  depression  is  irregularly  funnel-shaped  and  lobulated,  and  along  one  side  is  a  small  opening  no  larger 
than  a  pin-head.  The  picture  to  the  right  shows  the  cross-section  of  the  omphalomesenteric  duct  in  the  abdominal 
wall.  It  is  nearly  1  cm.  in  its  longest  diameter.  It  was  lined  with  typical  mucosa.  To  the  extreme  right  are  seen 
the  ligated  ends  of  the  omphalomesenteric  duct  and  the  urachus.     For  the  microscopic  picture  see  Fig.  214. 


Fig.  214. — Cross-section  of  the  Patent  Omphalomesenteric  Duct  and  of  the  Patent  Urachus  in  the  Same 

Child.  (Heflin's  case.) 
The  large  cavity  (a),  to  the  right,  is  the  lumen  of  the  omphalomesenteric  duct,  which  has  been  cut  slightly  on  the 
slant.  The  mucosa  is  drawn  up  into  long,  papillary-like  folds.  Surrounding  the  lumen  is  a  circular  layer  of  non-striped 
muscle.  The  small  cavity  (6)  to  the  left  is  what  remains  of  the  urachus.  This  cavity  was  partly  filled  with  debris 
containing  small  round-cells  and  some  polymorphonuclear  leukocytes.  The  tissue  immediately  surrounding  the  lumen 
was  very  delicate  in  texture  and  has  retracted  from  the  surrounding  dense  tissue.  The  elongate  dark  area  just  below 
the  lumen  is  a  lymph-nodule.  The  tissue  for  a  considerable  distance  around  the  urachus  was  infiltrated  with  small 
round-cells  and  polymorphonuclear  leukocytes.      (Photomicrograph  by  Mr.  Herman  Schapiro.) 


494 


THE    L^MBILICUS    AND    ITS    DISEASES. 


Hefiin  had  him  under  observation  for  some  time.  The  mother  would  bring  him 
every  day  or  two  for  examination.  He  became  paler  and  more  exsanguinated. 
The  bleeding  was  stopped  temporarily  sometimes  by  pressure,  sometimes  by  the 
use  of  the  cautery,  adrenalin,  or  hydrogen  dioxid,  but,  instead  of  diminishing,  the 
amount  of  hemorrhage  increased.     At  a  later  date  stick  silver  nitrate  was  used. 

Finally,  a  small  piece  of  the  umbilicus  was  cut 
outrfor  examination.  The  glands  found  in  it 
suggested  malignancy.  From  the  time  of  his 
birth  there  had  been  some  discharge  from  the 
umbilicus  which  had  an  odor  of  urine  and  at 
other  times  strongly  suggested  feces.  Finally 
Dr.  Hefiin  decided  that  the  only  proper  pro- 
cedure was  removal  of  the  umbilicus.  He 
made  an  elliptic  incision,  and  on  lifting  the 
umbilicus  out  found  that  there  was  a  contin- 
uous fistula  about  three  inches  long,  from  the 
umbilicus  to  the  small  bowel.  He  removed  it, 
and  treated  the  opening  in  the  bowel  precisely 
as  if  it  had  been  the  stump  of  an  appendix. 
The  mesentery  of  the  small  bowel  opposite  the 
point  of  this  opening  contained  quite  a  num- 
ber of  large  lymph-glands,  some  of  them  nearly 
1  cm.  in  diameter. 

He  also  found  a  second  tube  attached  to 
the  umbilicus,  which  passed  downward  to- 
ward the  bladder.  It  was  patent.  He  tied 
it  off  with  catgut  and  brought  it  up  into  the 
abdominal  incision.  The  abdominal  wound 
was  brought  together  without  difficulty  and 
the  child  made  a  good  recovery  (Fig.  215). 

Sections  through  the  mass  removed  by  Dr. 
Hefiin  from  the  umbilicus  show  two  distinct 
tubes.  One  is  almost  circular  and  nearly  1 
cm.  across;  the  other  about  2  or  2.5  mm.  in 
diameter.  The  larger  one,  on  histologic  ex- 
amination, is  found  to  be  lined  with  long, 
shaggy  intestinal  mucosa  of  the  type  found 
in  the  small  bowel  (Fig.  214) .  The  epithelium 
is  everywhere  intact.  Surrounding  the  mu- 
cosa is  a  circular  muscular  layer  and  outside 
of  this  again  a  cylindric  layer. 
The  smaller  tube  is  somewhat  disorganized.  Its  walls  are  surrounded  by 
muscle,  and  its  inner  surface  consists  in  large  measure  of  granulation  tissue  which 
has  become  organized.  The  nuclei  have  mostly  disappeared.  Clumps  of  poly- 
gonal cells  are  seen  here  and  there  clinging  to  the  wall.  Surrounding  the  lumen  are 
large  numbers  of  lymphoid  cells,  reminding  one  a  good  deal  of  young  lymph- 
glands.     In  the  walls  arc  polymorphonuclear  leukocytes  and  small  round-cells.    Un- 


flg.  215. a  plctube  of  the  child  three 

Weeks  after  Removal  of  a  Patent 
Omphalomesenteric  Duct  and  a  Patu- 
lous Qrachus.  He  is  Now  in  Good 
Health.     (Heflin's  catu.) 


CONGENITAL  PATENT  URACHUS.  495 

doiibtedly  the  tube  represents  the  degenerated  urachus.     In  this  case  there  was  a 
patent  omphalomesenteric  duct  and  also  an  open  urachus. 


REPORT  OF  CASES  OF  CHILDREN  BORN  WITH  A  PATENT  URACHUS. 

The  following  cases  represent  nearly  all  the  cases  we  could  find  in  the  literature. 
Some  in  which  the  history  was  inconclusive,  have  been  omitted. 

A  Patent  Urachus  with  a  Long  Projection  at  the  Um- 
bilicus. —  In  Alric's  Case  1*  the  patient  was  a  boy  ten  months  old,  seen  in 
1862.  He  was  well  developed,  but  had  at  the  umbilicus  a  tumor  3  to  4  cm.  long. 
This  was  regular,  round,  with  a  diameter  a  little  larger  than  that  of  a  goose-quill. 
It  was  firm  and  resembled  mucosa.  It  was  bright  red,  and,  as  in  Cabrol's  case,  bore 
a  marked  resemblance  to  the  comb  of  a  turkey-cock.  In  the  center  was  an  opening- 
having  the  diameter  of  a  fine  probe,  and  when  the  infant  cried,  urine  passed  from 
the  umbilicus  drop  by  drop.     Its  nature  was  recognized  by  the  color  and  odor. 

The  genital  organs  were  normal,  and  the  child  urinated  naturally  through  the 
urethra.     This  state  of  affairs  had  existed  since  birth. 

As  the  child  did  not  return  to  the  hospital,  no  operation  was  done. 

A  Patent  Urachus.  —  Alric's  Case  2f  was  seen  in  1873.  The  child 
was  five  years  of  age,  and  in  every  other  respect  seemed  to  be  healthy  except  that 
it  had  a  urinary  odor.  The  umbilical  depression  was  replaced  by  a  soft,  flabby, 
fungus-like,  dark-red,  somewhat  rounded  tumor,  the  size  of  a  walnut.  On  manipu- 
lation it  was  found  to  have  a  short  pedicle  about  the  size  of  a  pen-holder.  Con- 
tinually escaping  from  the  center  was  a  liquid,  recognized  by  its  odor  as  urine. 
When  the  bladder  contracted,  the  urine  escaped  more  freely  from  the  umbilicus; 
at  one  time  the  force  was  sufficient  to  cause  it  to  pass  out  in  a  jet.  The  urethra 
was  normal. 

The  tumor  was  raised  and  transfixed  with  a  needle  threaded  with  double-waxed 
thread.  The  loop  was  cut,  making  two  threads.  These  tied  both  halves  of  the 
tumor  firmly.  The  tumor  in  a  few  minutes  became  dark  and  separated  in  a 
few  days.  By  the  fifteenth  day  cicatrization  was  complete.  There  was  no  fur- 
ther escape  of  urine  and  the  boy  remained  well. 

A  Case  of  Unclosed  Urachus  with  Umbilical  Fistula.  J 
—The  patient  was  a  big,  strong,  healthy,  well-formed  man  thirty-nine  years  of  age. 
He  had  passed  a  portion  of  his  urine  through  the  umbilicus  ever  since  his  birth. 
When  he  urinated  in  the  upright  position,  about  two-thirds  would  come  out  of 
the  fistula  in  a  full  stream,  the  other  third  passing  by  way  of  the  urethra,  in  a  strong 
but  small  stream.  When  the  patient  was  lying  down,  the  urine  would  flow  out 
spontaneously  through  the  fistula — more  markedly  so  when  he  was  lying  on  his 
left  side.  He  had  to  pass  water  regularly  about  every  two  hours,  and  in  doing  this 
he  found  it  necessary  to  loosen  all  his  clothes  in  front  and  bend  forward.  His 
health  was  good,  but  on  one  or  two  occasions  he  had  passed  fine  calculous  material 
with  the  urine. 

The  genital  organs  were  well  formed.  The  abdominal  walls  were  perfect.  The 
umbilicus  was  a  little  flatter  than  usual.  In  the  center  was  an  opening  with  de- 
pressed margins.     The  opening  would  admit  the  tip  of  the  little  finger.     A  No.  12 

*  Alric:  Sur  deux  cas  de  persistance  de  l'ouraque.     Bull,  de  therapeutique,  1879,  xcvii,  34. 
t  Alric:  Loc.  cit.,  Case  2.  J  Annandale,  T.:  Edinb.  Med.  Jour.,  1870,  xv,  680. 


496  THE    UMBILICUS   AND    ITS    DISEASES. 

catheter  passed  easily  from  above  into  the  bladder.  There  was  no  excoriation.  A 
Xo.  6  catheter  passed  readily  through  the  urethra  into  the  bladder. 

Operation  was  suggested,  but  refused. 

Urachal  Fistula.  —  H.  R.  Wharton  reports  a  case  that  came  under 
Ashhurst's*  care.  The  patient  was  a  boy  nine  months  old.  At  the  umbilicus 
was  an  opening  through  which  urine  had  escaped  since  birth .  Occupying  the  posi- 
tion of  the  umbilicus  was  a  flattened  tumor  the  size  of  a  filbert.  It  was  covered 
over  with  mucosa,  and  in  its  center  was  a  depressed  opening,  through  which  the 
urine  escaped.     There  was  no  obstruction  in  the  urethra. 

The  actual  cautery  was  applied  to  the  fistulous  tract  and  the  projection  at  the 
navel  was  ligated.     Recovery  followed. 

Patent  Urachus.  —  Binnief  says  that  J.  D.  Griffith,  in  a  girl  fifteen 
years  of  age,  split,  cauterized,  and  packed  the  fistula  with  splendid  results.  In 
this  case  the  mother  said  that  there  had  been  more  or  less  umbilical  discharge  from 
the  time  the  cord  had  separated. 

A  Patent  Urachus.  —  In  1847  Cabell  J  examined  a  mulatto  girl  fourteen 
or  fifteen  years  old.  She  was  in  good  health,  but  had  an  umbilical  fistula,  through 
which  she  had  passed  urine  since  her  earliest  childhood.  Most  of  it,  however,  was 
passed  through  the  natural  channel.  She  claimed  to  have  the  power  of  passing  it 
either  way  at  will. 

The  umbilicus  presented  a  flattened,  disc-like  appearance  about  the  size  of  a 
quarter  of  a  dollar.  The  skin  around  it  was  loose  and  in  folds,  but  not  so  much  as 
to  attract  particular  attention  to  it.  In  the  center  was  a  small  aperture  of  the  usual 
appearance,  and  through  this  urine  escaped.  A  catheter  could  be  passed  six  to 
seven  inches  downward  toward  the  bladder,  and  urine  escaped  from  it.  The 
urethra  was  rather  smaller  than  usual. 

A  Patent  Urachus. §  —  The  patient  was  a  well-developed  boy  one  year 
old.  The  urine  was  first  noticed  escaping  from  the  umbilicus  when  the  cord  dropped 
off.  From  the  urethra  it  was  passed  with  difficulty,  coming  only  in  drops.  No 
tumor  was  noted  at  the  umbilicus,  but  the  urine  filled  the  umbilical  cup  and  ran 
over. 

The  prepuce  was  long,  contracted,  and  adherent  to  the  glans.  The  child  was 
circumcised,  and  the  urine  later  was  projected  through  the  urethra  some  distance, 
very  little  coming  away  from  the  umbilicus. 

Charles  says  that  sometimes  it  is  necessary  to  operate  on  the  fistula.  He  did 
not  do  so  in  this  case,  and  the  cure  was  not  complete. 

A  Patent  Urachus.  ||  —  The  patient,  C.  F.,  was  five  and  a  half  years  of 
age.  The  baby  had  at  the  umbilicus  a  small,  violet-colored  tumor,  the  size  of  a 
currant.  At  the  age  of  six  months  this  small  tumor  began  to  grow;  it  became  promi- 
nent and  enlarged  considerably,  until  it  reached  the  size  of  a  strawberry.  Some 
time  later  an  orifice  formed  at  its  summit,  from  which  a  stream  of  serosanguineous 
fluid  escaped.     This  was  never  examined.    Since  that  time,  according  to  the  mother, 

*  Ashhurst:  Med.  News,  Philadelphia,  1882,  xli,  122. 
t  Binnie,  J.  F.:  Jour.  Amer.  Med.  Assoc.,  1906,  xlvii,  109. 
%  Cabell,  R.  G.:  Amer.  Jour.  Med.  Sci.,  Philadelphia,  1848,  n.  s.,  xv,  313. 
§  Charles,  J.  J.:  The  Treatment  of  Patent  Urachus.     Brit.  Med.  Jour.,  1875,  ii,  486. 
||  Delageniere,  H.:   Traitement  de  l'ouraque  dilate  et  fistuleux  par  la  resection  et  la  suture. 
Une  observation.     Arch,  provinc.  de  chir.,  1892,  i,  222. 


CONGENITAL  PATENT  URACHUS. 


497 


there  had  been  sometimes  a  cessation  of  the  discharge,  but  then  immediately  there 
had  developed  a  severe  pain  at  the  umbilical  region.  It  was  on  acccount  of  this 
pain  that  the  mother  sought  surgical  aid. 

On  examination  the  child  was  well  nourished,  but  rather  backward  in  develop- 
ment, and  looked  more  like  a  four-year-old  child  than  one  of  five  and  a  half.  The 
umbilicus  was  the  seat  of  marked  irritation.  It  was  deformed  and  showed  a 
transverse  furrow,  dividing  it  into  two  halves,  an  upper  and  a  lower,  both  of  which 
were  indurated  and  red.  This  furrow  measured  about  2  cm.,  and  was  surrounded 
by  an  inflammatory  zone  several  centimeters  broad,  which  presented  multiple 
erosions  of  the  skin  and  several  indurated  points — veritable  hard  nodules.  The 
principal  one  was  situated  3  cm.  below  the  fold  of  the  umbilicus.  Through  the 
furrow  it  was  possible  to  introduce  a  probe  and  pass 
it  easily  downward  toward  the  nodule  mentioned. 
The  fluid  escaping  from  the  umbilicus  was  usually 
clear  and  transparent,  sometimes  tinged  with 
blood,  chiefly  when  the  child  walked.  The  urine 
escaped  from  the  urethra  in  a  jet,  and  a  short  time 
afterward  some  could  be  seen  coming  from  the  um- 
bilicus. When  the  urine  ceased  to  pass  by  the 
urethra,  the  discharge  from  the  umbilicus  in- 
creased. 

On  May  2,  1892,  a  median  incision  was  made. 
The  tissue  on  section  had  a  lardaceous  appearance. 
The  operator  entered  into  an  excavation  lined  with 
f  ungosities  and  numerous  diverticula.  This  cavity 
was  cureted.  In  the  lower  part  was  a  pocket  into 
which  a  sound  could  be  introduced.  Delageniere 
decided  to  remove  the  sac  (Fig.  216).  He  opened 
it  and  entered  the  peritoneal  cavity.  He  then 
easily  recognized  the  urachus,  which  showed  as  a 
duct  lined  with  smooth  mucous  membrane.  The 
duct  was  isolated  for  a  distance  of  3  cm.  and  li- 
gated.  The  sac  was  then  removed,  a  drain  intro- 
duced, and  the  abdomen  closed.  The  patient 
made  a  satisfactory  recovery. 

A  Patent  Urachus.  —  Draudt*  de- 
scribes the  case  of  Fritz  R.,  six  months  old.  For  several  weeks  a  clear  fluid  had 
been  escaping  from  the  umbilicus.  Whether  it  had  begun  almost  immediately 
after  birth  was  not  known.  The  child  was  healthy  and  otherwise  normally  formed. 
The  umbilical  ring  was  completely  closed.  There  was,  however,  an  escape,  drop  by 
drop,  of  a  clear,  acid-reacting  fluid  from  the  umbilicus.  After  a  4  per  cent,  solution 
of  indigo-carmin  was  introduced  into  the  gluteus  muscle,  the  urine  from  the  urethra 
and  the  fluid  from  the  umbilicus  both  took  on  a  deep  blue  color.  There  was  a 
phimosis,  but  the  stream  from  the  urethra  was  fairly  well  developed. 

Operation. — Professor  Lexer,  with  the  patient  in  the  Trendelenburg  position, 
made  an  incision  around  the  umbilicus  and  continued  it  to  within  a  fmgerbreadth 


(After 


Fig.  216. — A  Patent  Urachus. 
Delageniere.) 
Anteroposterior  section  through  the 
lower  part  of  the  abdomen.  P,  perito- 
neum; V,  the  bladder;  O,  the  urachus; 
U,  the  urinary  pouch;  a,  the  orifice  of 
the  fistula  at  the  umbilicus. 


*  Draudt,  M. 
1907,  lxxxvii,  487. 
33 


Beitrag  zur  Kenntnis  der  Urachusanomalien.     Deutsche  Zeitschr.  f.  Chir. 


498 


THE    UMBILICUS    AND    ITS    DISEASES. 


of  the  symphysis  (Fig.  217).  The  incision  was  deepened  and  the  parts  dissected 
free.  On  the  posterior  surface  of  the  cord,  passing  from  the  umbilicus  to  the  blad- 
der, the  peritoneum  was  very  thin.  The  opening  in  the  bladder- wall  was  closed 
with  a  continuous  mattress  suture,  which  was  reinforced,  and  the  abdomen  was 
closed. 

The  specimen  was  7  cm.  long,  with  a  canal  about  2  mm.  in  diameter  extending 
throughout  its  entire  length.     About  1.5  cm.  from  the  outer  skin,  at  the  umbilicus, 
the  lumen  became  wider.     It  was  funnel-shaped  and  passed  gradually  into  the  skin. 
The  portion  toward  the  bladder  was  similarly  arranged.     The  funnel-like  dilata- 
tion imperceptibly  passed  over  into 
the  bladder  mucosa.     There  was  no 
evidence  of  a  fold  or  of  a  valve. 

Microscopic  examination  gave 
findings  similar  to  those  obtained  by 
Luschka,  Suchannek,  and  Wutz.  The 
inner  surface  of  the  tube  was  every- 
where lined  with  several  layers  of 
epithelium,  usually  three  layers  in 
thickness. 

A  Patent  Urachus  As- 
sociated with  a  Partially 
Obliterated  Urethra.*  — 
In  the  case  of  K.  B.,  a  male  infant 
one  day  old,  no  evidence  of  a  urethra 
was  found  externally  and  the  bladder 
did  not  seem  to  be  very  full.  Under 
these  circumstances  a  urethral  orifice 
was  sought  for  in  the  perineum.  The 
entire  bulbus  was  laid  free  and  care- 
fully examined,  but  no  urethra  was 
discovered.  The  opening  made  in  the 
perineum  was  not  closed.  The  dress- 
ings a  few  hours  later  were  found  to 
be  moist.  Injections  of  indigo-carmin 
into  the  gluteus  muscles  did  not,  how- 
ever, give  a  very  clear  blue  color.  The 
moisture  on  the  clothes  continued,  but  no  opening  corresponding  to  the  urethra  could 
be  seen.  After  gradually  becoming  weaker,  the  child  died  when  fourteen  days  old. 
At  autopsy  it  was  found  possible  to  remove  the  urachus,  bladder,  and  urethra  intact. 
(Fig.  218  gives  a  typical  picture  of  the  condition.)  The  bladder  itself  was  spindle- 
shaped,  approximately  4  cm.  in  length.  At  its  broadest  point  it  measured  2  cm. 
in  diameter.  The  walls  were  very  thick,  especially  near  the  fundus.  The  mucosa 
was  folded.  The  ureters  opened  at  the  normal  points.  Projecting  from  the 
fundus  was  a  canal  1.8  cm.  long  and  about  5.5  mm.  in  diameter.  This  passed 
gradually  into  the  funnel-like  opening  at  the  top  of  the  bladder,  and  there  was  no 
evidence  of  a  fold-like  formation  at  the  junction  of  the  bladder  with  the  canal. 
The  tube  was   lined  with   epithelium,  extended   to   the  umbilicus  and  was  open 

*Draudt,  M.:   Loc.  cit. 


Umbilicus 


Urachus 


Bladder 


Peritoneum 


X 


Fig 


217. — A  Urachus  Open  from  Bladder  to  Umbili- 
cus.    (After  Draudt.) 
The  child  is  in  the  Trendelenburg  posture.     The  umbili- 
cus has  been  encircled  by  the  incision,  and  the  cord  dissected 
free  to  the  bladder.     It  was  cut  off  at  the  top  of  the  bladder, 
and  the  bladder  closed.     The  patient  made  a  good  recovery. 


CONGENITAL  PATENT  URACHUS. 


499 


/ 


Umbilicus 


Remains  of 
umbilical 
arteries 


Urachus 


\ 


there.  The  opening,  being  not  over  0.1  mm.  in  diameter,  macroscopically  was 
hardly  visible,  but  in  serial  sections  the  condition  became  apparent.  The  inner 
surface  was  lined  with  a  very  definite  epithelium,  four  or  five  layers  in  thickness. 
The  superficial  epithelium  was  also  cylindric  in  character. 

On  examination  of  the  urethra  it  was  found  that  the  bulbous  portion  followed  an 
eccentric  course  and  lay  to  the  left.  In  the  course  of  the  urethrotomy  it  had  been 
cut  a  little, — sufficiently  to  allow  urine  to  escape, — but  not  enough  to  be  recognized 
macroscopically.  The  urethra  was  eccentric  and  ended  as  a  connective-tissue 
thread  about  2  cm.  beneath  the  point  of  the  glans.  This  case  belongs  to  the  rather 
rare  group  of  defects  of  the  urethra  in  its  glandular  portion.  Kaufmann,  in  1886, 
could  find  only  11  cases  of  this  anomaly. 

Vesi  co-umbilical    Fistula.*  —  This   case  was  also  recorded  by 
Dupuytren  and  Roux  and  also  forms  Gueniot's  Obser- 
vation 5. 

Madam  L.  brought  a  male  child  twenty-three  and 
one-half  months  old  to  the  hospital  on  May  14,  1810. 
The  child  looked  well.  From  birth  he  had  presented 
a  remarkable  and  extraordinary  phenomenon.  Part 
of  the  urine  had  passed  from  the  urethra  and  part 
from  the  umbilicus.  The  umbilicus  was  radiating 
in  form,  and  in  the  center  could  be  seen  the  um- 
bilical extremity  of  the  urachus.  At  the  umbilicus 
at  birth  was  an  oblong  tumor.  The  cord  was  situ- 
ated in  the  middle  of  the  extremity  of  this  tumor, 
which  was  red  and  bloody.  After  the  cord  had 
dropped  off  the  boy  had  commenced  to  emit  jets 
of  urine  from  the  umbilicus.  The  extremity  of  the 
tumor  was  always  red,  and  covering  it  was  a  small 
quantity  of  pus.  In  the  course  of  fifteen  days  the 
tumor  assumed  a  more  favorable  aspect.  It  com- 
menced to  cicatrize,  and  after  six  weeks  healing  was 
complete,  but  the  fistula  persisted. 

A  Patent  Urachus  in  a  Child  Four 
Years  0  1  d  .  f  —  In  this  child,  four  years  of  age, 
there  was  a  leakage  of  urine  from  the  umbilicus.  At 
times  the  stream  was  from  four  to  twelve  inches  high. 

The  boy  was  well  nourished,  had  normal  genital  organs,  and  voided  some  of 
his  urine  from  the  urethra. 

At  the  umbilicus  was  a  large,  mushroom-like  eversion  fully  half  an  inch  high, 
with  a  crater-like  center.  The  entire  structure  was  covered  with  epithelium,  and 
showed  no  erosions.  In  the  center  there  was  a  small  cicatricial  area  surrounding 
the  opening,  which  admitted  an  ordinary  probe.  The  boy  was  kept  under  obser- 
vation and  was  found  to  have  a  fairly  good  stream  from  the  urethra. 

Operation. — A  probe  could  be  passed  from  side  to  side  like  a  pendulum,  showing 


Bladder 


\ 


Fig.  218. — An  Open  Urachus. 
(After  Draudt.) 
The  bladder  is  spindle-shaped. 
The  upper  portion  is  narrow  and 
gradually  passes  over  into  the  open 
urachus,  which  can  be  followed  up 
to  the  umbilicus. 


*  Marx:  Enfant  de  vingt-trois  mois  et  demi,  qui  rendait  Purine  en  partie  par  la  verge  et  en 
partie  par  l'ouverture  ombilicale  de  l'ouraque.  Repertoire  general  d'anatomie  et  de  physiologie 
pathologique,  1827,  iv,  120. 

f  Erdmann,  John  F.:   Pediatrics,  1908,  xx,  356. 


500  THE    UMBILICUS    AND    ITS    DISEASES. 

a  rather  wide  urachus  with  a  diameter  of  fully  half  an  inch.  A  free  incision  was 
made  from  an  inch  above  the  pubes  to  the  umbilicus.  In  dissecting  the  urachus 
free  the  operator  made  several  small  openings  in  the  peritoneum.  The  bladder 
was  fusiform  in  shape,  and  the  urachus,  which  was  three-quarters  of  an  inch  wide 
and  about  three  inches  long,  was  apparently  continuous  with  the  bladder  itself. 
The  umbilicus  was  excised,  and  about  an  inch  of  the  urachus  with  the  umbilicus 
cut  off.  Direct  apposition  sutures  were  then  applied,  followed  by  a  circular  row 
below,  with  inversion  of  the  sutured  portion,  as  in  the  case  of  an  appendix  stump. 
A  third  row  of  catgut  sutures  was  placed  over  the  inverted  end,  and  the  abdominal 
wound  closed.  A  catheter  was  placed  in  the  bladder  and  kept  in  three  days.  The 
boy  made  a  good  recovery,  and  was  discharged  on  the  seventeenth  day. 

A  Patent  Urachus.  —  Florentin*  quotes  Cabrol's  case.  In  the  year 
1550,  in  the  village  of  Beaucaire,  there  was  an  exhibition  by  the  village  guard  before 
the  house  of  Mile,  de  Varie.  Several  of  the  young  ladies  were  accidentally  in- 
jured. When  treating  these  patients,  Cabrol  noticed  a  most  offensive  odor  of 
urine,  and  tried  to  find  out  the  cause.  The  next  day  he  examined  a  girl  and  found 
at  the  umbilicus  an  elongation  the  length  of  four  fingerbreadths,  resembling  the 
crest  of  a  turkey-cock,  whose  urine  is  passed  through  the  cloaca.  The  surgeon 
was  at  once  impressed  with  the  danger  of  closing  this  opening  without  allowing 
the  urine  to  pass  by  the  ordinary  channel.  The  girl  was  eighteen  years  of  age.  He 
found  the  vesical  orifice  closed  by  a  membrane.  He  opened  this  and  passed  a  lead 
cannula  into  the  bladder.  The  next  day  he  closed  the  opening  at  the  umbilicus. 
It  had  entirely  healed  by  the  twelfth  day. 

A  Patent  Urachus.  —  Florentinf  reports  a  case  of  urinary  fungus 
in  a  girl  of  four  years,  from  the  clinic  of  Professor  Froelich.  She  was  admitted  to 
the  surgical  department  for  fistula  at  the  umbilicus.  At  birth  nothing  abnormal 
was  noted.  The  cord  came  away  on  the  ninth  day.  At  that  time  the  mother 
noticed  at  the  base  of  the  umbilical  cicatrix  a  tumor  the  size  of  a  small  pea.  This 
discharged  continuously  a  whitish  liquid  with  the  odor  of  urine.  Since  that  time 
the  tubercle  had  gradually  increased  in  volume,  the  discharge  had  persisted  and 
produced  a  marked  erythema  at  the  orifice  of  the  umbilicus.  This  condition  had 
persisted  for  four  years,  without  any  interference  with  the  health  of  the  child. 
On  examination,  at  the  base  of  the  umbilical  fold  was  seen  a  violet-colored  tumor 
the  size  of  a  pea.  A  probe  could  be  introduced  downward  and  backward.  The 
tumor  was  irreducible.  There  was  no  hernia  at  the  umbilicus.  At  intervals  a  drop 
of  clear  liquid  with  a  urinous  odor  escaped. 

Operation. — The  tumor  was  encircled  and  dissected  down  to  the  peritoneum. 
All  that  could  be  drawn  out  was  cut  off  and  the  wound  closed.  Microscopic  examina- 
tion showed  an  outer  coat  of  connective  tissue,  then  the  cell-fibers  of  non-striped 
muscle,  and  in  the  center  a  duct  lined  with  pavement  epithelium.  The  child  made 
a  good  recovery. 

A  Patent  Urachus.  J  —  A  male  child,  two  or  three  months  old,  was 
brought  to  Professor  Helmuth's  College  Clinic  in  1885.  The  nurse  who  accompanied 
the  child  said  that  it  passed  urine  through  the  umbilicus.  On  examination  an  out- 
growth, about  an  inch  and  a  quarter  in  length,  was  discovered  in  this  locality.     It 

*  Cabrol:    Quoted  by  Florentin,  P.:    Fongus  de  l'ombilic  chez  le  nouveau-ne  et  chez  1'en- 
fant.  These  de  Nancy,  1908-09,  No.  22. 

t  Florentin,  P.:  Op.  fit,,  obs.  9.  \  Freer:  Annals  of  Surg.,  1887,  v,  107. 


CONGENITAL  PATENT  URACHUS.  501 

was  hollow  and  was  connected  by  a  completely  pervious  urachus  with  the  bladder. 
This  point  was  proved  by  the  continuous  discharge  of  urine  through  it.  The  urine 
excoriated  the  parts  and  rendered  the  child  exceedingly  uncomfortable.  The 
method  of  treatment  suggested  for  the  deformity  was  ligation  of  the  excrescence, 
but,  owing  to  the  absence  of  the  child's  parents,  this  was  deferred. 

A  Patent  Urachus. —  Freer*  says  that  in  cases  of  vesico-umbilical 
fistula  several  methods  of  treatment  have  been  devised.  He  cites  the  case  of  a  child 
of  five  months.  The  urachus  was  completely  pervious  and  admitted  a  medium- 
sized  catheter.  At  its  umbilical  extremity  was  an  outgrowth  that  resembled  a 
strawberry.  This  was  encircled  with  a  subcutaneous  ligature  and  removed;  the 
edges  were  pared  and  sutured,  and  complete  closure  followed. 

A  Case  of  Fleshy  Tumor  of  the  Umbilicus  with  Patent 
Urachus.  —  French's!  patient  was  a  female  six  weeks  old.  There  was  at  the 
umbilicus  a  hernia-like  protrusion  of  the  skin  about  three-quarters  of  an  inch  in 
length,  surmounted  by  a  red  fleshy  outgrowth,  like  a  swollen  and  fungoid  glans 
penis.  Whenever  the  child  cried  or  struggled,  this  growth  became  very  prominent 
and  vascular,  and  through  a  small  opening  urine  was  expelled. 

Operation. — After  it  had  been  determined  that  no  knuckle  of  intestine  was  in  the 
way,  a  harelip  pin  was  driven  through  the  fleshy  mass  at  its  junction  with  the  cuticle 
and  transversely  to  the  body  axis.  Beneath  this  and  at  right  angles  to  it  a  needle 
armed  with  a  stout  double  ligature  was  passed,  and  the  threads  were  drawn  through. 
These  were  tied  tightly  on  each  side  under  the  pin.  The  fleshy  mass  came  away 
with  the  pad  on  the  third  day.  On  the  tenth  day  the  wound  had  completely  healed 
and  was  covered  with  skin.     An  umbilical  truss  was  ordered  as  a  simple  precaution. 

Escape  of  Urine  from  the  Umbilicus.  % — The  patient  was  a 
boy  of  twelve  who,  for  three  years,  had  had  an  oval  tumor  directly  above  the  sym- 
physis. It  was  about  the  size  of  a  hen's  egg.  The  overlying  skin  was  tender  and 
apparently  inflamed,  but  showing  no  great  amount  of  reaction.  To  theleft  of  the 
tumor  was  an  oblique  cleft  about  9  mm.  long.  It  was  through  this  opening 
that  the  child  urinated,  but  drop  by  drop,  as  from  a  still.  Below  the  tumor  was  a 
transverse  opening,  from  which  air  escaped  with  some  noise,  and  there  was  some- 
times a  foul  odor.  Immediately  beneath  this  was  another  tumor,  which  may  have 
been  a  penile  gland.  The  penis  was  not  perforated.  Goupil  asks  how  the  urine 
could  come  from  the  umbilicus,  but  quotes  Graf,  Diemerbroeck,  du  Laurent,  Fernel, 
and  others  as  having  seen  it  escaping.  He  wonders  whether  the  foul  odor  could  have 
been  from  the  bowel,  but  says  that  no  feces  were  passed  through  the  umbilicus. 

A  Patent  Urachus. §  —  This  case  was  recorded  in  the  Deutsche  Klinik, 
1864,  xvi,  116.  A  man  twenty-eight  years  of  age  had  a  urachal  fistula  at  birth. 
This  was  healed  after  the  employment  of  escharotics.  Twenty-five  years  later  a 
tumor  developed  between  the  umbilicus  and  the  symphysis.  This  broke  and  dis- 
charged pus,  then  urine.  Autopsy  revealed  a  carcinoma  of  the  mucosa  of  the 
urachus,  which  had  perforated  into  the  umbilicus  and  the  bladder. 

Possibly  a  Patent  Urachus. ||  —  This  case  was  reported  in 
Vaughan's  article.     No  reference  is  given  as  to  the  original  source. 

*  Freer:   Loc.  cit.  t  French,  John  G.:  The  Lancet,  London,  1882,  i,  60. 

t  Goupil:  Sur  un  vice  de  conformation  singuliere.     Jour,  de  med.  de  Paris,  1756,  v,  108. 
§  Graf,  Fritz:   Urachusfisteln  und  ihre  Behandlung.     Inaug.  Diss.,  Berlin,  1896. 
||  Griffith,  F.:   See  Vaughan,  G.  T.:  Trans.  Amer.  Surg.  Assoc,  1905,  xxiii,  273. 


502 


THE    UMBILICUS    AND    ITS    DISEASES. 


The  patient  was  a  male  infant  five  months  old,  from  whose  navel  there  had  been 
a  discharge  of  clear  fluid  ever  since  the  detachment  of  the  cord.  This  fluid  was 
colorless,  limpid,  and  did  not  have  a  urinous  odor.  The  parts  were  kept  clean, 
dressed  frequently,  and  adhesive  plaster  was  used  to  approximate  the  edges.  After 
three  months  recovery  took  place. 

A  Patent  U  r  a  c  h  u  s  .  *  —  The  child  was  presented  before  the  Society  of 
Surgery  first  at  the  meeting  on  June  5,  1872;  and  during  the  second  meeting  on 
July  10th,  several  days  after  complete  healing  had  taken  place.  Gueniot  says  that  it 
is  incontestable. that  the  continuity  of  the  vesical  cavity  with  the  persistent  canal  of 
the  urachus  has  been  confirmed  in  a  certain  number  of  cases  in  the  bodies  of  adults. 

He  says  that  Albinus,  Beudt,  and  Haller  have 
reported  examples  of  this  character. 

On  June  1,  1872,  Alfred  R.,  ten  and  a  half 
months  old,  was  admitted  to  Gueniot's  service. 
He  was  in  good  general  health,  but  had  a  tumor 
at  the  umbilicus.  This  was  dull  red,  had  a  mu- 
cous surface,  was  moist,  and  resembled  a  cherry 
in  form,  color,  and  volume.  It  was  2.2  cm.  in 
diameter,  and  was  attached  at  the  umbilicus 
by  a  pedicle  6  to  8  mm.  long  and  16  mm.  broad. 
It  was  rather  soft  and  covered  with  delicate 
skin.  On  pressure  it  was  irreducible.  The 
umbilical  ring  was  enlarged,  slightly  indurated, 
and  hypertrophied,  and  formed  a  circular  eleva- 
tion which  increased  in  size  with  any  movement 
of  the  child.  There  was  weakness  at  the  umbili- 
cal ring.  The  tumor  looked  like  a  mushroom 
with  a  short  pedicle.  Finally — and  this  is  the 
most  important  point — there  was  an  expulsion 
of  a  transparent  liquid  from  the  orifice  in  the 
tumor,  and  the  patient  also  urinated  in  the 
natural  way.  There  was,  in  other  words,  a 
urinary  fistula,  with  hernia  and  hypertrophy 
of  the  mucosa  at  the  umbilicus.  The  genital 
organs  were  well  developed.  The  testicles 
appeared  to  have  been  arrested  at  the  rings. 
On  June  10th,  after  several  ineffectual  attempts  at  compression  and  the  employ- 
ment of  iron  perchlorid  and  zinc  chlorid,  Gueniot  ligated  the  umbilical  tumor.  This 
caused  pain,  and  at  the  same  time  he  noticed  redness  of  the  tumor.  The  passage  of 
urine  was  not  stopped.  On  the  twelfth  a  second  ligature  was  applied  at  the  same 
point.  On  the  fifteenth  he  noticed  that  the  tumor  had  ulcerated  circularly,  and 
where  the  ligature  had  been  applied  there  was  a  deep  furrow.  The  surface  of  the 
ulcer  was  cauterized  with  silver  nitrate  and  a  new  ligature  applied.  On  the  nine- 
teenth the  discharge  of  urine  from  the  umbilicus  still  persisted ;  the  ulceration  at  the 
base  of  the  tumor  had  increased,  and  the  furrow  had  become  deeper.  The  fourth 
ligature  was  applied  and  tied  more  tightly  than  the  one  preceding.     This  time  the 

*  Gueniot,  R.:    Des  fistules  urinaires  de  l'ombilic  dues  a  la  persistance  de  l'ouraque,  et  du 
1  raitement  qui  leur  est  applicable.     Bull,  de  therapeutique,  1872,  lxxxiii,  299;  348. 


Fig.  219. — Escape  of  Urine  from  the  Um- 
bilicus Due  to  a  Patent  Urachus. 
(After  Gueniot.)  ■ 

The  upper  picture  represents  the  urine 
escaping  from  the  umbilicus  prior  to  opera- 
tion. Surrounding  the  opening  is  a  dark  area 
where  there  had  been  a  rolling  out  of  the  mu- 
cosa. The  lower  picture  shows  the  umbilicus 
after  operation.  Cicatrization  is  perfect. 
There  is  no  escape  of  urine. 


CONGENITAL  PATENT  URACHUS.  503 

tumor  was  markedly  congested,  and  on  the  twentieth  for  the  first  time  the  urine 
ceased  to  pass  from  the  umbilicus.  The  tumor  was  black  and  gangrenous.  On  the 
twenty-second  there  was  a  marked  diminution  in  the  secretion  from  the  umbilicus 
and  no  escape  of  urine.  The  tumor  was  dead.  On  the  twenty-fourth  the  ligature 
came  away,  and  by  the  twenty-eighth  the  umbilicus  had  assumed  a  more  normal 
conformation.  The  pedicle  of  the  tumor  had  diminished  markedly  in  its  dimensions, 
and  nothing  but  a  small  tubercle  about  the  size  of  a  pea  remained.  There  was  no 
farther  escape  of  urine,  and  the  child  was  discharged  well. 

A  Partially  Patent  Urachus.*  —  This  case  is  quoted  by  Simon 
(Obs.  4).  (I  have  been  unable  to  locate  the  original  article.)  He  says  that  during 
the  year  1648  Haran  received  at  the  Hotel-Dieu  a  new-born  child  who  had  at  the 
umbilicus  a  tumor  the  size  of  a  pigeon's  egg.  This  contained  clear  fluid  and  was 
adherent  to  the  extremity  of  the  cord  below  the  ligature.  It  was  opened  in  the 
presence  of  several  people,  and  there  escaped  a  serous  fluid  which  proved  to  be  urine. 
Urine  then  escaped  in  abundance.  All  present  thought  that  it  came  from  the  bladder. 

A  Patent  Urachus.  f  —  Case  1. — The  patient  was  a  male  child  who, 
when  five  weeks  old,  began  to  discharge  urine  from  the  umbilicus.  There  was 
inflammation  resulting  from  extravasation  of  urine  around  the  umbilicus.  The 
extravasation  spread  all  over  the  abdomen  and  the  child  died  in  a  few  days. 

A  Partially  Patent  Urachus. t  —  Case  3. — The  patient  was  a  girl 
four  years  of  age  who  had  a  chronic  discharge  from  the  umbilicus  and  pain  between 
the  umbilicus  and  symphysis.  A  probe  was  passed  nearly  to  the  vertex  of  the  blad- 
der. The  urachus  was  ligated  and  cut  and  then  treated  in  exactly  the  same  manner 
as  the  vermiform  appendix.  No  opening  was  detected  at  the  bladder.  The  peri- 
toneum was  accidentally  opened  during  the  operation.     The  child  recovered. 

A  Patent  Urachus.  §  —  The  patient  was  a  vigorous  boy,  fifteen  years  of 
age.  Since  infancy  he  had  sometimes  lost  urine  at  night  through  the  umbilicus. 
During  the  day  the  bladder  had  held  it  better. 

In  a  discussion  following  the  presentation  of  Hue's  case,  one  physician  asked  if 
the  tract  could  not  have  been  injected  with  some  substance  impermeable  to  the 
x-ray  and  then  a  radiograph  made.  Another  suggested  the  introduction  of  milk  or 
some  coloring-matter  to  see  if  it  would  pass  into  the  bladder. 

A  Patent  Urachus.  —  On  April  20,  1911,  I  received  from  Dr.  PL  H. 
Huggins,  of  Pittsburgh,  the  following  abstract  from  one  of  his  histories: 

"  The  patient  was  the  third  child  of  a  healthy  mother.  It  weighed  seven  and  a 
half  pounds.  It  was  well  developed  and  apparently  normal  in  every  way.  About 
ten  days  after  delivery  the  nurse  called  attention  to  the  escape  of  fluid,  from  the 
umbilicus.  Examination  revealed  an  opening  in  the  lower  border  of  the  umbilical 
ring.  This  was  surrounded  by  a  small  inflamed  area  by  which  urine  escaped  at 
times,  not,  however,  in  large  quantities,  but  sufficient  to  saturate  the  bandage  and 
neighboring  clothing.  A  small  probe  was  passed  to  a  point  about  4  cm.  from  the 
bladder.  Repeated  cauterizations  for  about  four  weeks  effected  a  closure  of  the 
fistula  and  there  was  no  further  trouble." 

*  Haran:   La  pratique  des  accouchements,  i,  38. 

fHind,  W.:  Diseases  of  the  Urachus  and  Umbilicus.  Brit.  Med.  Jour.,  London,  1902,  ii, 
242. 

t  Hind,  W.:   Loc.  cit. 

§  Hue,  Francois:  Persistance  du  canal  de  l'ouraque;  fistule  ombilicale.  La  Xormandie 
medicale,  1905,  xx,  311. 


504  THE    UMBILICUS    AND    ITS    DISEASES. 

A  Patent  Urachus.*  —  This  case  was  reported  in  Vaughan's  article. 
I  have  not  been  able  to  obtain  the  original. 

A  girl,  aged  six  years,  had  passed  urine  from  the  umbilicus  from  the  twelfth  day, 
that  is,  from  the  time  that  the  cord  dropped  off. 

The  urachus  was  excised,  and  the  lower  end  ligated  with  catgut.  The  wound 
was  closed,  leaving  the  end  of  the  catgut  ligature  projecting.  The  patient  had 
scarlet  fever,  and  the  wound  opened  superficially,  but  it  was  reunited  and  healed 
without  further  trouble. 

A  Patent  Urachus.  —  Jacoby'sf  patient  was  a  strong,  normally  devel- 
oped boy,  but  he  had  an  unusually  thick  cord.  Jacoby  tied  the  cord  himself.  The 
umbilical  ring  was  the  size  of  a  silver  gulden.  After  the  cord  came  away  the  wound 
was  the  same  size.  It  rapidly  became  smaller,  so  that  in  three  weeks  it  formed 
nothing  but  a  funnel-shaped  opening,  but  a  few  weeks  after  this  the  nurse  casually 
mentioned  that  the  umbilicus  was  often  wet  or  filled  with  water.  On  investigation 
it  was  found  that  there  was  a  fine  fistulous  opening  through  which  fluid  escaped 
when  the  bladder  was  full.  The  water  came  drop  by  drop  and  filled  the  umbilicus. 
The  opening  was  so  small  that  a  sound  could  not  be  made  to  enter  it. 

Jaeoby  tried  compression,  which  answered  very  well  until  the  pressure  was 
removed.  Later  he  tried  the  actual  cautery,  and  as  soon  as  the  slough  had  come 
away  he  drew  the  surfaces  together.  This  procedure  proved  successful  after  the 
second  treatment.  The  umbilicus  became  ditch-like  instead  of  funnel-shaped,  and 
no  trace  of  the  fistula  remained. 

A  Patent  Urachus.  —  JahnJ  reports  a  case  coming  under  Mikulicz's 
care.  A  boy  five  years  of  age  was  seen  in  February,  1895.  There  was  no  hereditary 
taint.  Soon  after  his  birth  the  parents  noticed  that  he  passed  little  urine  in  the 
natural  way,  but  that  an  abundance  escaped  by  the  umbilicus. 

On  examination  the  boy  was  found  to  be  well  developed.  The  umbilicus  was 
the  size  of  a  mark  piece,  flat  and  prominent,  and  gathered  into  radial  folds.  In  the 
middle  was  a  funnel-shaped  depression  from  which,  when  abdominal  pressure  was 
made,  urine  escaped.  A  sound  6  mm.  in  diameter  passed  without  difficulty  14  to 
16  cm.  downward  toward  the  symphysis,  and  could  be  moved  freely  in  all  directions, 
there  being  no  indication  of  a  septum.  When  the  umbilical  opening  was  closed,  the 
boy  could  urinate  well  by  the  urethra,  but  in  a  small  stream.  A  catheter  could  be 
readily  carried  into  the  bladder,  and  a  sound  introduced  from  above  came  into  direct 
contact  with  it. 

A  cystoscope  introduced  from  above  passed  into  the  bladder,  and  a  careful 
examination  of  the  viscus  was  thus  rendered  possible.  A  diagnosis  of  congenital 
umbilical  fistula,  due  to  an  open  urachus,  was  made. 

Mikulicz,  on  February  5,  1895,  cut  around  the  umbilicus  and  dissected  the  canal 
free  for  3  cm.  Here  it  passed  over  into  the  apex  of  the  bladder.  During  the  dis- 
section  the  peritoneum  was  opened  at  one  point.  This  opening  was  closed.  The 
urachus  with  its  opening  into  the  bladder  was  cut  away,  and  the  wound  in  the  bladder 
closed.  The  abdominal  walls  were  brought  together,  a  small  gauze  drain  being 
passed  down  to  the  bladder  sutures. 

*  Imbert,  I..:  See  Yuughan,  G.  T.:  Trans.  Amer.  Surg.  Assoc,  1905,  xxiii,  273. 

t  Jacoby,  M.:  Zur  Casuistik  der  Nabelfisteln.     Berlin,  klin.  Wochenschr.,  1877,  xiv,  202. 

+  Jahn,  A.:  Ueber  Urachusfisteln.  Beitrage  z.  klin.  Chir.,  Tubingen,  1900,  xxvi,  323. 


CONGENITAL  PATENT  URACHUS. 


505 


The  boy  was  able  to  urinate  on  the  next  day.  The  result  was  excellent,  and 
three  and  a  half  years  later  the  boy  was  still  well. 

Jahn  gives  a  very  good  review  of  the  literature. 

A  Patent  Urachus.*  —  The  patient  was  a  child  seven  months  old  (sex 
not  given).  It  had  been  passing  urine  from  the  umbilicus  since  birth.  At  the 
umbilicus  was  a  sort  of  flattened,  button-shaped  tumor,  the  size  of  a  cherry.  It  was 
red,  and  evidently  due  to  everted  mucosa  at  the  umbilicus.  A  probe  passed  into  the 
urachus  three  inches.     The  greater  part  of  the  urine  was  passed  by  the  urethra. 

A  Patent  Urachus.  —  Lannelongue'sf  patient  was  a  child  three 
months  old.  The  mother  said  that  it  had  two  penises,  and  that  it  urinated 
from  both  at  the  same  time  (Fig.  220). 
One  penis  was  normal;  the  other  organ 
was  situated  at  the  umbilicus,  and  looked 
exactly  like  a  normal  penis.  The  child 
died  later.  There  was  an  umbilical 
hernia  and  a  patent  urachus  which  had 
been  tied  off  with  the  cord;  hence  there 
had  resulted  a  fistula  when  the  cord  came 
away. 

A  Patent  Urachus.}  —  In 
the  case  of  Meyer-Kempen  the  urine 
escaped  in  a  stream  from  the  umbilicus 
when  the  child  cried.  Ledderhose  says 
that  excoriations  of  the  skin  in  the  neigh- 
borhood of  the  fistula  may  or  may  not  be 
present.  As  long  as  the  urine  is  acid,  the 
irritation  of  the  skin  is  only  small  in 
amount.  In  some  cases  ecchymosis  has 
been  noted.     The  prognosis  is  good. 

A  Fistula  of  the  U  r  a  - 
c  h  u  s  .  §  —  The  patient  was  a  female 
child.  On  the  seventh  day  the  cord, 
which  was  still  partially  attached,  was 
cut  with  scissors.  In  a  few  days  the 
clothes  at  the  umbilicus  were  wet.  The 
discharge   of    fluid   continued.      Litmus 

paper  showed  that  the  umbilical  fluid  had  an  acid  reaction.  When  the  child 
was  examined,  a  small,  soft  tumor,  reddish  violet  in  color,  and  with  a  small 
hole  in  its  center,  was  noted  at  the  umbilicus.  A  probe  was  easily  passed  3  cm. 
downward  toward  the  bladder.  The  child  was  taken  to  the  country  five  weeks 
after  birth.  Little  by  little  the  fluid  diminished  and  then  disappeared.  Five 
months  later  the  child  was  perfectly  well. 

*  Kennedy,  A. :  Brit.  Med.  Jour.,  London,  1899,  i,  1396. 

t  Lannelongue :  Un  cas  de  faux  penis  ombilical.  Lecons  de  clinique  chirurgicale,  Paris, 
1905,  388. 

i  Ledderhose,  G.:  Chirurgische  Erkrankungen  des  Xabels.  Deutsche  Chirurgie,  1890, 
Lief.  45  b,  109. 

§  Lugeol :  Fistule  urinaire  ombilicale  par  persistance  de  l'ouraque.  Jour,  de  med.  de  Bordeaux, 
1S79-80,  ix,  3. 


Fig.  220. — A  Patent  Urachus  tvith  a  Penile  Pro- 
jection at  the  Umbilicus.  (After  Lanne- 
longue.) 

The  penile  projection  at  the  umbilicus  conformed 
in  shape  and  size  to  the  penis  of  a  child.  The  urine 
escaped  from  the  urethra  and  also  from  the  umbilicus. 


506  THE    UMBILICUS    AND    ITS    DISEASES. 

Congenital  Vesico-umbilical  Fistula.*  —  The  child,  a  year 
old,  had  an  opening  at  the  umbilicus  through  which,  when  it  cried,  the  urine  escaped 
in  a  stream.  The  opening  had  the  form  of  a  urethral  orifice.  The  umbilicus  was 
thickened  and,  although  no  hernia  existed,  it  was  prominent  and  in  its  contour 
resembled  a  glans  penis.  When  the  child  was  quiet,  the  urine  passed  by  the  urethra, 
but,  when  abdominal  pressure  was  made  or  the  child  cried,  it  came  in  a  stream 
from  the  umbilical  opening.  The  urachus  had  evidently  remained  patent.  Opera- 
tion was  refused  by  the  parents. 

A  Patent  Urachus. f  —  Monod,  on  pp.  122  and  123  of  his  splendid 
treatise,  gives  somewhat  full  tabulations  of  the  cases  heretofore  recorded. 

On  p.  124  he  reports  a  case  of  congenital  urinary  fistula  at  the  umbilicus  clue  to 
persistence  of  the  urachus:  G.  G.,  aged  ten,  admitted  to  the  hospital  in  June,  1899. 
When  the  cord  came  away  there  was  a  plaque  the  size  of  a  franc  at  the  umbilicus. 
The  urine  escaped  from  it  and  also  from  the  urethra.  The  flow  was  intermittent. 
He  had  never  had  any  tumor  at  the  umbilicus.  The  orifice  was  small,  but  admitted 
without  pain  a  No.  13  bougie.  Around  the  opening  the  skin  was  like  scar  tissue  and 
showed  transverse,  raised  folds  radiating  from  the  periphery  to  the  center.  The 
surrounding  skin  was  smooth.  .The  sound  could  be  introduced  through  the  fistula 
into  the  bladder.  At  times  the  urine  passed  from  the  umbilicus,  at  other  times 
from  the  urethra.  Sometimes  all  of  it  was  passed  from  the  umbilicus  and  a  few 
drops  only  from  the  meatus.  At  other  times  the  reverse  occurred,  and  occasionally 
all  the  urine  passed  by  the  urethra  and  none  by  the  fistula.  The  child  had  a  phimo- 
sis, but  there  was  no  obstruction  in  the  urethra. 

The  entire  urachal  tract  was  removed.  Histologic  examination  showed  that  the 
cavity  was  lined  with  a  stratified  squamous  epithelium  similar  to  that  of  the  skin. 

A  Patent  Urachus  that  Closed  and  Reopened  Later  in 
Life  as  a  Result  of  Hypertrophy  of  the  Prostate.  —  MonodJ 
describes  a  case  seen  by  Jaboulay  and  reported  in  1897.  The  patient  was  a  man, 
sixty-two  years  of  age,  who  had  been  in  good  health  up  to  that  time.  He  had  pain- 
ful micturition  and  symptoms  of  hypertrophy  of  the  prostate,  the  diagnosis  being 
confirmed  on  examination.  One  day  after  painful  micturition  he  noticed  that 
drops  of  urine  with  a  fetid  oclor  were  escaping  from  the  umbilicus.  The  quantity 
of  urine  that  escaped  the  first  time  was  probably  150  to  200  c.c.  He  entered  the 
hospital  for  the  fistula,  and  said  that  he  had  never  had  any  accident,  but  that  his 
mother  had  often  told  him  that  shortly  after  birth  he  was  treated  for  escape  of 
urine  at  the  umbilicus,  and  that  the  discharge  had  disappeared  in  the  course  of 
fifteen  days  after  the  application  of  an  appropriate  bandage. 

The  urachus  was  dissected  out  for  3  or  4  cm.  and  tied  off.  Later,  however,  it 
reopened. 

Operation  for  Pervious  Urachus.  §  —  The  patient  was  a  female 
child  four  months  old.  The  urine  escaped  from  the  umbilicus,  keeping  the  bed- 
clothes soaked.     When  the  umbilical  folds  were  drawn  apart,  an  opening  which 

*  Meyer:   Offenbleiben  des  Urachus  nach  der  Geburt.     Casper's  Wochenschr.  f.  d.  gesammte 

Heilkunde,  is  11,  424. 

f  Monod,  Jean:  Des  fistules  urinaires  ombilicales  dues  a  la  persistence  de  l'ouraque.  These 
de  Paris,  1899,  62. 

t  Monod,  Jean:  Op.  cit.,  184. 

§  Paget  and  Bowman:  On  an  Operation  for  Pervious  Urachus.  Medico-Chir.  Trans.,  Lon- 
don, 1861,  xliv,  13. 


CONGENITAL  PATENT  URACHUS.  507 

would  admit  a  lead-pencil  was  found  and  the  skin  was  inverted.  When  the  skin  was 
drawn  apart,  urine  gushed  out.  The  circumference  of  the  opening  was  denuded, 
and  the  edges  coapted  with  a  suture  pin  and  lint,  as  in  a  case  of  harelip.  On  the 
third  day  a  small  amount  of  urine  escaped  by  the  umbilicus.     The  result  was  perfect. 

A  Case  in  Which  the  U  r  a  c  h  u  s  Remained  Open  and  the 
Ring-shaped  Calculus  that  had  Formed  upon  a  H  a  i  r 
in  the  Bladder  was  Extracte  d  T  h  r  o  u  g  h  t  h  e  U  m  bili- 
ous.* — ■  The  patient,  John  Conquest,  an  ironfounder,  aged  forty,  had  for  a 
year  or  more  suffered  from  frequent  and  painful  micturition.  He  also  said  that, 
when  attempting  to  pass  water  or  when  doing  strenuous  work,  urine  would 
escape  from  the  navel.  On  being  questioned  it  was  found  that  from  the  time  of 
his  birth  some  of  the  urine  had  come  away  from  the  umbilicus — a  clear  indication 
of  a  patent  urachus. 

He  was  admitted  to  the  Leicester  Infirmary  on  August  15,  1844.  Paget,  on 
sounding  him,  readily  made  out  a  vesical  calculus,  and  further  found  that  the  sound 
could  be  carried  up  through  the  bladder  to  the  umbilical  open- 
ing. Hoping  that  it  might  be  possible  to  remove  the  vesical 
stone  through  the  umbilicus,  he  temporarily  plugged  the  um- 
bilical opening,  distended  the  bladder  with  warm  water,  and 
placed  the  patient  upon  a  Heurteloup  table  with  his  head  lower 
than  the  pelvis;  in  other  words,  he  put  the  patient  in  what  we 

1  '  Fig.     221.  —  A    Rixg- 

now  call  the  Trendelenburg  posture.     The  plug  was  now  re-  shaped     vesical 

moved,  and  a  ringer  introduced  into  the  umbilical  opening.  Calculus  with  a 

'  °  ii  Fine   Hair  in  its 

The  tip  of  the  finger  caught  in  the  center  of  the  ring-shaped  cal-  axis.  (After  Paget 

cuius  (Fig.  221),  and  with  care  Paget  was  able  to  extract  the  and  Bowman.) 

•  i  i     ,i  i  "V       i  •  mi'  i       i  This    calculus   had 

stone  through  the  umbilical  opening.  This  calculus  was  ring-  formed  on  a  hair  in  the 
shaped  because  it  had  developed  around  a  curled-up  hair.  bladder  and  was  ex- 

-n  .  ,i  ,i  i  -t  ,i  -ii  tracted  through  the  um- 

Paget  says  that  at  the  umbilicus  there  was  a  circular  de-  biiicus.  The  calculus 
ficiency  in  the  linea  alba  one  inch  in  diameter.     The  margins        was  as  thick  as  a  me- 

r  ,i   •  ,i   •    i  i  i       r  ,•!  t_        j  i  dium-sized  writing  quill. 

of  this  ring  were  thickened  and  of  cartilaginous  hardness,  and  The  urachus  was  patent 
through  the  opening  protruded  a  hernial  mass  the  size  of  a  throughout, 
goose's  egg.  This  hernia  was  covered  over  with  mucous  mem- 
brane which  became  dry  when  exposed  to  the  air  for  any  length  of  time.  The  patient 
could  not  pass  water  when  this  hernia  was  out,  and  when  he  tried  to  void,  the  pro- 
jection gradually  withdrew  into  the  abdomen,  and  urine  then  forcibly  escaped  from 
the  umbilicus,  and  in  a  moderate  stream  from  the  urethra. 

It  was  clearly  evident  that  the  muscular  walls  of  the  bladder  made  traction  on 
the  umbilical  hernial  projection.  Paget  says  that  the  bladder  and  urachus  formed 
a  urinary  receptacle  that  in  shape  might  be  compared  with  a  curved-necked  cupping- 
glass. 

The  description  of  the  case  strongly  suggests  a  partial  exstrophy  of  the  bladder. 

After  the  extraction  of  the  calculus  the  man  was  relieved  of  his  bladder  symp- 
toms.    No  attempt,  however,  was  made  to  repair  the  congenital  defect. 

Paget  again  saw  the  man  in  April,  1860.  f  When  the  patient  was  fifty-five  years 
old  (Paget  said)  the  opening  in  the  linea  alba  was  elliptic  in  shape,  and  admitted 

*  Paget  and  Bowman:  Medico-Chir.  Trans.,  pub.  by  the  Royal  Med.  and  Chir.  Soc,  London, 
1850,  2.  ser.,  xv,  293. 

tLoc.  cit.,  1861,  xliv,  13. 


508  THE    UMBILICUS    AND    ITS    DISEASES. 

three  fingers.  In  the  mean  time  the  man  had  developed  a  second  vesical  calculus. 
This  was  disc-shaped  and  had  come  away.  Paget,  after  passing  a  finger  through 
the  umbilical  opening  into  the  bladder,  to  exclude  the  possibility  of  another  calculus, 
successfully  closed  the  umbilical  opening. 

A  Yesico-umbilieal  Fistula.  —  Pauehet's*  patient  was  a  boy  five 
vears  of  age.  Shortly  after  the  cord  came  awaj^  a  large  mass  of  "proud  flesh"  was 
noted  at  the  umbilicus,  and  from  it  a  clear  fluid  with  a  urinary  odor  escaped.  The 
discharge  of  fluid  would  occur  at  intervals  of  four  or  five  days,  persist  for  one  or  two 
days,  coming  unexpectedly  and  never  in  a  jet,  and  accompanied  b}'  abdominal  pain. 
The  granular  area  was  destroyed  with  silver  nitrate. 

When  seen,  the  boy  was  emaciated.  A  Xo.  6  bougie  passed  the  urethra  easily. 
The  fistula  admitted  a  bristle,  which  penetrated  3  or  4  cm.  without  giving  any  indi- 
cation of  the  direction  of  the  canal.  The  umbilicus  occupied  its  normal  site  and  was 
surrounded  by  an  area  of  induration  about  1  cm.  in  diameter.  On  palpation  of  the 
abdomen  some  urine  escaped  from  the  umbilicus.  There  existed  in  reality  a  retro- 
peritoneal pocket,  at  one  end  communicating  with  the  bladder,  at  the  other  with  the 
umbilical  fistula.  The  amount  of  urine  discharged  from  the  navel  during  the 
twenty-four  hours  was  about  80  c.c.  There  was  no  cystitis.  Urination  was  pain- 
less, not  too  frequent,  and  the  urine  was  clear. 

The  existence  of  a  retro-umbilical  pocket  was  not  known  prior  to  operation.  A 
median  incision  was  made  3  cm.  above  the  fistula,  encircling  the  umbilicus  and 
extending  to  within  2  cm.  of  the  pubes.  After  obtaining  good  exposure  b}^  separat- 
ing the  muscles  Pauchet  freed  the  tissues  around  the  umbilicus  and  the  subjacent 
tissue  and  made  traction.  He  was  easily  able  to  detach  a  fibrous  mass  the  size  of  a 
walnut  from  the  peritoneum  without  opening  the  peritoneal  cavity.  The  urachus 
was  then  visible  as  a  delicate,  transparent  cord,  resembling  an  empty  vein.  It 
passed  to  the  summit  of  the  bladder.  It  was  tied  off  with  catgut  and  severed.  The 
stump  was  turned  in  with  a  catgut  suture  and  the  abdominal  wound  closed  with 
interrupted  sutures.     Xo  drainage  was  employed.     The  wound  healed  in  ten  days. 

The  ovoid  mass  was  the  size  of  a  walnut.  Its  surface  was  adherent  to  the  sur- 
rounding skin,  and  at  its  center  was  the  fistula.  The  lower  extremity  of  the 
mass  was  continuous  with  the  urachus  for  a  length  of  3  cm.  On  section,  the  cavity 
resembled  a  small  and  contracted  bladder.  The  walls  were  fibrous,  and  the  mucosa 
presented  a  large  number  of  folds. 

A  Patent  Urachus.  —  In  1887  Pennyf  reported  the  case  of  a  healthy 
child,  aged  eleven  months,  who,  after  separation  of  the  cord  on  the  ninth  day,  had 
been  passing  urine  through  the  navel.  A  probe  passed  into  the  fistula  could  be  felt 
to  touch  a  catheter  passed  up  the  urethra  into  the  bladder. 

After  the  cord  came  away  the  umbilicus  was  represented  by  a  raised  rounded 
mass  the  size  of  a  hazelnut.  Its  surface  was  intensely  red  and  covered  with  mucosa. 
A  constriction  fxistfjd  at  the  junction  with  the  abdomen.  Surrounding  the  umbili- 
cus was  a  dusky  red  areola,  about  one  inch  in  width,  due  to  irritation  from  the 
fluid.     In  the  center  was  a  sinus  through  which  the  urine  escaped. 

Operation  was  declined. 

*  Pauchet.  V.:  Fistule  ombilico-vesicale.  Resection  sous-peritoneale  de  l'ouraque  et  d'un 
poche  urineuse  n'tro-ombilicale,  guerison.  Bull,  et  Mem.  de  la  Soc.  de  chir.  de  Paris,  1902,  xxviii, 
785. 

t  Penny,  W.  J.:  Bristol  Medico-Chir.  Jour.,  1888,  vi,  30. 


CONGENITAL  PATENT  URACHUS.  509 

A  Congenitally  Patent  Urachus.  —  Petit's*  patient  in  Case 
4  was  a  young  boy  who,  since  his  birth,  had  had  an  escape  of  urine  from  the  umbili- 
cus. At  the  navel  was  a  kind  of  cushion,  in  the  middle  of  which  was  a  round 
opening  through  which  the  urine  escaped.  There  was  no  obstruction  in  the  urethra 
because  the  urine  passed  also  by  the  natural  way,  and,  when  the  patient  did  not 
wear  a  bandage,  it  escaped  also  from  the  umbilicus. 

Urinary  Fistula  at  the  Umbilicus.  —  Pierre'sf  patient  was  a 
boy  with  a  congenital  urinary  fistula  at  the  umbilicus,  without  any  obstruction  in 
the  urethra.  At  the  umbilicus  was  a  ring,  2  cm.  in  diameter,  in  the  center  of  which 
was  an  irregular  opening  5  mm.  in  diameter.  Behind  this  was  a  discoid  cavity 
from  which  a  small  amount  of  urine  escaped.     No  operation  is  mentioned. 

A  Patent  Urachus.  —  In  1876  PrestonJ  saw  an  infant  so  malformed 
that  its  sex  could  not  be  determined.  It  had  an  opening  through  the  umbilicus 
from  which  urine  came.  The  child  weighed  nine  pounds.  Two  years  later  it  was 
still  passing  urine  from  the  umbilicus,  but  was  in  good  health.  The  mother  informed 
Preston  that  there  was  never  any  urinary  odor  on  the  diapers  used  to  receive  the 
feces,  indicating  that  little  or  no  urine  escaped  from  the  urethra. 

A  Case  of  Congenital  V  e  s  i  c  o  -  u  m  b  i  1  i  c  a  1  Fistula — ■ 
Patent  Urachus. §  —  The  patient  was  a  boy  eleven  years  of  age.  At  birth 
there  was  a  rounded  swelling  in  the  umbilical  region  the  size  of  a  duck's  egg.  It  was 
easily  reduced  and  kept  in  place  by  a  bandage.  Urine  escaped  from  this  swelling. 
Up  to  his  seventh  year  compresses  were  used,  but  these  were  of  little  value.  On 
examination  the  boy  was  found  to  be  strong.  In  the  center  of  the  umbilicus  was  an 
opening  which  admitted  a  uterine  sound.  Urine  passed  by  the  urethra  and  also  by 
the  umbilicus.  Jacobi  saw  the  child  and  passed  a  catheter  from  the  umbilicus  into 
the  bladder. 

Operation. — A  raw  surface  was  made  above  the  fistula;  a  flap  was  dissected  up 
from  below  and  attached  to  the  raw  area.  At  the  end  of  a  week  a  small  amount  of 
urine  escaped  from  the  umbilicus,  but  the  opening  soon  closed  after  the  use  of  silver 
nitrate.  A  year  later  Jacobi  introduced  12  ounces  of  water  into  the  bladder  through 
the  urethra  and  none  escaped  from  the  umbilicus. 

A  Series  of  Cases  with  Patent  Urachus.  —  Smit||  reported 
three  cases: 

Case  1:  A  woman,  aged  fifty-eight,  complained  of  retention  of  urine  which 
dribbled  from  the  navel.  A  vesicovaginal  fistula  was  established  and  the  urachus 
closed  spontaneously.     Later  the  vesicovaginal  fistula  closed. 

Case  2:  A  girl  aged  seventeen  had  constant  dribbling  of  urine  from  the  navel; 
also  of  blood  at  the  menstrual  period.  The  edges  of  the  fistula  were  split  and  a 
purse-string  suture  applied,  with  a  perfect  result. 

Case  3 :  A  boy,  one  and  a  half  years  old,  had  an  offensive  discharge  of  urine 
from  the  navel.  There  was  also  an  eczematous  condition  at  the  umbilicus.  The 
boy  had  marked  phimosis.  Circumcision  failed  to  cure  the  fistula.  The  navel  was 
excised  and  the  urachus  successfully  closed  with  a  purse-string  suture. 

*  Petit,  J.  L.:  Traitedes  maladies  chirurgicales,  Chap,  xi,  3.  Oeuvres  completes.  8°.  Limoges, 
1837,  799.     (Quoted  from  Simon.) 

f  Pierre:  Bull.  Soc.  de  med.  de  Rouen,  1888,  2.  serie,  ii,  32. 

X  Preston,  W.:  Med.  Record,  New  York,  1898,  liv,  315. 

§  Rose,  A.:  Med.  Record,  1877,  xii,  516. 

||  Smit,  J.  A.  R. :  Abstract  from  Zentralbl.  f.  Gym,  1904,  Nr.  41. 


510  THE    UMBILICUS    AND    ITS    DISEASES. 

It  is  not  stated  in  these  cases  whether  the  urine  had  passed  from  the  umbilicus 
from  birth.     We  are  including  them  all  as  instances  of  patent  urachus. 

A  n  Ope  n  U  r  a  c  h  us.  —  Smith*  reported  the  case  of  a  boy,  aged  two 
years,  who  had  a  papilla-like  projection  at  the  umbilicus.  In  the  center  of  this  was 
an  opening  from  which,  at  all  times,  there  transuded  a  fluid  looking  and  smelling  like 
urine.  A  ligature  was  firmly  applied  to  this  projection,  and  after  a  few  days  it  dried 
up  and  fell  off.     The  fistula  seemed  to  be  permanently  closed. 

Fistula  of  the  Urachus.  —  Stadfeldt  t  reports  a  case  of  fistula  of  the 
urachus  and  gives  a  table  of  cases  from  the  literature.  [Xo  translation  of  the 
article  could  be  obtained.] 

Escape  of  Urine  fro  m  the  Umbilicus.  —  Starr's i  patient  was 
a  female  child  thirteen  weeks  old.  Since  birth  the  urine  had  escaped  from  the  um- 
bilicus. The  urethra  was  normal.  The  flow  from  the  umbilicus  was  not  continu- 
ous, but  occurred  at  intervals,  regulated  by  the  detrusive  action  of  the  bladder. 
The  general  appearance  of  the  umbilicus  was  larger  and  more  open  than  usual,  and 
in  the  center  of  the  cartilaginous,  nipple-like  projection  was  an  orifice  which  ad- 
mitted an  ordinary  probe.  This  passed  in  the  direction  of  the  linea  alba  toward 
the  bladder.  Starr  diagnosed  the  condition  as  one  of  open  urachus,  although  he 
pointed  out  that  a  leading  authority  claimed  that  the  urachus  was  open  only  in 
those  cases  in  which  the  urethra  was  closed. 

The  Radical  Cure  of  a  Patent  Urachus. §  —  The  patient  was 
a  tall  youth,  seventeen  years  of  age,  who  had  had  urine  escaping  from  the  umbilicus 
since  birth.  The  umbilicus  bulged  forward;  there  was  a  small  hernia  of  subperi- 
toneal fat  and  an  eczematous  condition  around  the  umbilicus.  The  patient  had 
always  had  some  pain  when  voiding. 

Operation. — The  bladder  was  emptied  and  four  ounces  of  boric  solution  were 
allowed  to  run  in.  A  transverse  incision  was  made  one  inch  above  the  symphysis. 
The  recti  muscles  were  separated,  and  a  good  view  of  the  bladder  and  its  peritoneal 
reflection  was  obtained.  In  caliber  the  urachus  was  as  large  as  the  stem  of  a  clay 
pipe.  The  part  close  to  the  bladder  was  clamped,  a  second  clamp  was  applied  high 
up  and  a  cut  made  between.  A  purse-string  of  celluloid  thread  was  placed  around 
the  vesical  stump  of  the  urachus,  and  the  latter  was  invaginated  as  in  dealing  with  an 
appendix.  The  umbilical  end  of  the  urachus  was  brought  up  out  of  the  abdomen 
between  the  recti  muscles  and  anchored  to  the  muscle,  and  the  sheath  covered  over 
with  fat  and  skin.  Further  dissection  was  not  made  on  account  of  the  eczematous 
condition  of  the  skin.     The  patient  made  a  good  recovery. 

A  Patent  Urachus.  —  Stierlinj]  reports  the  case  of  a  twelve-year-old  girl 
brought  to  the  hospital  on  June  28,  1896.  At  the  umbilicus  was  an  opening  from 
which  urine  flowed.  During  the  daytime  only  a  small  amount  escaped,  but  at  night 
so  much  came  away  that  practically  every  morning  the  bed  was  wet  through.  The 
urine  escaped  only  drop  by  drop  from  the  umbilicus.  There  was  never  any  pain. 
This  watery  discharge  from  the  umbilicus  was  noted  as  soon  as  the  umbilical  cord 

*  Smith,  Thomas:   Mel.  Times,  London.  1863,  new  series,  i,  320. 

f  Stadfeldt,  A.:  Bidrag  til  Laren  om  den  medfodte  Yesiko-umbilikalfistel  i Urachus-fisteln)  og 
dens  Behandling.     Nordiskt  Mediciniskt  Arkiv,  Stockholm,  1871,  iii,  Xo.  23,  1. 
Starr,  T.  II.:   Med.  '1  a z.,  London,  1844,  xxxiii,  484. 
5  evens,  B.  Crossfield:  The  Lancet,  London,  1904,  ii,  584. 

Stierlin,  Ii.:   Zur  Casuistik  angeborener  Xabelfisteln.     Deutsche  med.  Wochenschr.,  1897, 
xxiii,  1  38. 


CONGENITAL  PATENT  URACHUS.  511 

came  away.  The  child  was  well  nourished.  The  umbilicus  was  flat,  broad,  and 
about  3  cm.  in  diameter.  In  its  lower  portion  was  a  depression  toward  which  the 
skin  on  all  sides  passed  in  radiating  folds.  The  umbilical  ring  was  wide,  so  that  the 
point  of  the  finger  could  be  passed  into  it.  If  the  patient  coughed,  the  upper  part  of 
the  umbilicus  became  distended.  In  addition,  in  the  linea  alba  there  was  a  small 
prominence  the  size  of  a  pea.  Stierlin  diagnosed  the  case  as  one  of  hernia  of  the 
linea  alba.  The  depression  in  the  lower  part  of  the  umbilicus  formed  the  entrance 
to  a  large,  roomy,  fistulous  canal.  When  pressure  was  made  upon  the  hypogas- 
trium,  several  drops  of  clear  fluid  with  a  urinary  odor  escaped.  A  No.  9  bougie 
could  be  passed  into  the  fistula  with  ease  and  entered  a  cavity.  When  a  metallic 
sound  was  introduced  through  the  urethra  at  the  same  time,  both  instruments  were 
found  to  have  entered  the  bladder. 

Operation. — On  both  sides  of  the  fistula  the  skin  was  divided  in  transverse 
directions  for  1.5  cm.  The  walls  were  freshened  up,  and  the  urachus  closed  with 
continuous  catgut.  The  abdominal  walls  were  then  brought  together  and  a  catheter 
was  placed  in  the  bladder.  There  was  no  hematuria,  and  the  patient  made  a  good 
recovery. 

Patulous  Urachus  in  a  Child  of  Nine  Months.*  —  The 
patient  was  a  negro  girl  nine  months  of  age.  Ever  since  the  separation  of  the  cord 
she  had  discharged  urine  from  the  umbilicus.  At  the  navel  was  a  protruding  mass 
of  granulation  tissue,  but  bulging  only  about  one-sixteenth  of  an  inch  from  the  skin. 
In  its  center  was  an  opening.  In  five  or  six  weeks  a  cure  was  effected  after  cauter- 
ization of  the  orifice  several  times  at  various  intervals. 

A  Patent  Urachus  That  Closed  in  the  Fourth  Year 
and  Opened  Again  at  Forty-eight.  —  Tuholske's  f  patient  was 
a  man  fifty-two  years  of  age,  who  in  infancy  had  passed  urine  through  the  umbilicus. 
This  condition  ceased  in  his  fourth  year  without  treatment,  and  he  had  no  further 
trouble  until  he  was  forty-eight  years  of  age,  when,  apparently  without  cause,  the 
urine  again  commenced  to  flow  through  the  navel.  The  margins  of  the  opening 
were  pared  and  sewed  together,  but  without  effecting  a  cure.  Six  months  later  the 
canal  was  exposed  by  incision,  and  half  an  inch  beyond  the  margin  was  found  to 
spread  out  into  the  bladder,  no  division  existing  between  the  bladder  and  urachus. 
The  urachus  was  split  down  to  what  should  have  been  the  summit  of  the  bladder 
and  sewed  across  for  a  distance  of  two  inches.  The  operation  was  extraperitoneal. 
Recovery  followed. 

Congenital  Sinus  of  the  Urachus.  —  Vander Veer,|  in  1886, 
saw  in  consultation  with  Dr.  DuBois,  a  female  twenty  years  of  age  who,  since  the 
tenth  day  after  her  birth,  had  discharged  urine  from  the  umbilicus  at  irregular  in- 
tervals. For  the  last  two  years  she  had  had  pain,  the  discharge  had  become  offensive, 
and  the  parts  about  the  umbilicus  had  become  excoriated.  A  probe  passed  down- 
ward toward  the  symphysis  for  three  inches.     The  sinus  lay  just  extraperitoneally. 

The  operation  consisted  in  slitting  up  the  urachus,  curetting,  suturing  the  lower 
part,  and  packing  the  upper  part  with  iodoform  gauze.     Recovery  followed. 

A  Patent  Urachus.  —  Velpeau  §  reports  a  case  of  a  boy  two  years  of  age, 

*  Stites,  T.  H. :  Amer.  Medicine,  Philadelphia,  1903,  vi,  136. 

f  Tuholske,  H. :  St.  Louis  Medical  Review,  February  11,  1905.     (From  Vaughan's  article.) 

t  Vander  Veer,  A.:  Med.  and  Surg.  Reporter,  1889,  lxi,  661. 

§  Velpeau:  Arch,  de  med.,  1826,  xi,  554.     (Quoted  from  Gueniot,  obs.  6.) 


512  THE    UMBILICUS    AND    ITS    DISEASES. 

who  was  seen  in  consultation  by  Professor  Ronx  for  congenital  tumor  of  the  umbili- 
cus. The  child  was  in  a  condition  of  continuous  suffering.  The  greater  part  of  the 
urine  escaped  from  the  urethra.  The  umbilical  tumor  was  the  size  of  a  walnut  and 
resembled  a  fungus.  It  was  bright  red,  and  in  its  center  was  an  orifice  from  which 
the  urine  continued  to  pass.  It  escaped  when  the  child  cried  or  moved.  A  small 
sound  was  left  in  the  urethra,  and  in  the  course  of  three  weeks,  when  this  had  done 
no  good,  an  elastic  bandage  was  put  on  to  compress  the  tumor.  It,  however,  pro- 
duced an  ulcer  without  diminishing  the  discharge. 

Patent  Urachus  in  a  Child  Five  Months  Old.  Opera- 
tion. Recovery.  —  Waller,*  in  1884,  had  a  male  patient,  five  months  old, 
who  had  passed  urine  through  the  umbilicus  ever  since  the  cord  had  separated.  The 
aunt  said  that  the  child  had  a  tumor  growing  from  the  navel  and  that  this  had  gradu- 
ally become  larger  since  birth.  Caustics  had  been  applied  several  times  without 
result.  At  the  umbilicus  was  a  tumor  about  1  inch  in  diameter.  This  apparently 
consisted  of  a  flabby  granulation  tissue.  It  was  red,  inflamed,  and  very  sensitive. 
From  a  slight  depression  at  its  summit  drops  of  urine  were  constantly  oozing.  The 
drops  came  fast  when  the  child  micturated.  The  skin  around  the  tumor  was  excori- 
ated.    The  child  was  otherwise  well. 

Under  anesthesia,  a  catheter  could  be  passed  from  the  umbilicus  to  the  bladder. 
The  urachus  formed  a  cord  the  thickness  of  the  little  finger,  and  during  the  dissection 
the  peritoneum  was  opened.  The  upper  part  for  one  inch  was  removed;  the  lower 
part  was  ligated  with  silk.     The  parts  united  and  recovery  followed. 

Operation  for  Open  Urachus.  —  De  Forest  Willard,f  in  1888,  re- 
ported the  case  of  a  female  child,  two  years  of  age,  who  had  passed  urine  through 
the  urachus  ever  since  birth,  about  half  a  dram  escaping  during  the  course  of  the  day. 
There  was  a  spot  two  inches  in  diameter  about  the  umbilicus  where  the  epithelium 
was  excoriated,  and  from  which  there  was  an  offensive  discharge.  The  urethra  was 
free.     The  labia  minora  were  adherent  in  front  of  the  orifice. 

Several  vain  attempts  were  made  to  close  the  opening  by  cauterization  with 
silver  nitrate.  An  operation  was  undertaken,  and  the  edges  of  the  navel  were 
freshened  up.  Union  resulted,  but  in  a  month  the  wound  broke  down  and  the  dis- 
charge returned.  The  parts  were  then  opened,  curetted,  cauterized,  and  a  drain- 
age-tube was  put  in.     A  cure  resulted. 

A  Patent  Urachus  —  Urachus  Cysts. |  — A  woman,  twenty- 
eight  years  of  age,  from  her  birth  up  to  three  years  of  age  had  discharged  urine 
from  the  umbilicus.  The  opening  was  closed  by  the  use  of  escharotics,  but  in  her 
twenty-seventh  year  cancer  developed  at  the  open  umbilicus.  This  perforated 
into  the  abdominal  cavity,  and  the  patient  died  of  acute  peritonitis. 

A  Pervious  Urachus.  §  —  The  patient  was  a  male,  three  weeks  old. 
When  the  cord  came  away  a  protuberance  half  an  inch  long,  with  blood  oozing  from 
the  surface,  was  noted  at  the  umbilicus.  From  this  urine  had  passed  ever  since  the 
cord  had  come  away.  In  the  center  was  a  slight  depression  that  freely  admitted 
a  small  probe,  which  could  be  passed  into  the  bladder. 

*  Waller,  C.  B.:   Med.  Bull.,  Philadelphia,  1885,  vii,  371. 
t  Willard,  De  Forest:   Med.  News,  Philadelphia,  1888,  liii,  710. 

\  Wolff.  Carl  Christian:  Beitrag  zur  Lehre  von  den  Urachuscysten.  Inaug.  Diss.,  Marburg, 
1  ^74,  Case  3. 

§  Yates,  \Y.  S.:   Phila.  Med.  Journal,  1902,  x,  173. 


CONGENITAL  PATENT  URACHUS.  513 

The  umbilical  opening  was  closed  with  a  purse-string  suture  passed  around  the 
protruding  portion  subcutaneouslv;  the  protruding  part  was  then  cut  off.  The 
wound  healed  and  there  was  no  further  trouble. 


LITERATURE  CONSULTED  ON  CONGENITAL  PATENT  URACHUS. 
Alric:  Sur  deux  cas  de  persistance  de  l'ouraque.     Bull,  de  therapeutique,  1879.  xcvii,  34. 
Annandale,  T.:  Case  of  Inclosed  LTrachus  with  Umbilical  Fistula.     Edinb.  Med.  Jour.,  1870,  xv, 

680. 
Ashhurst:  Urachal  Fistula.     Med.  News,  Philadelphia,  1882,  xli,  122. 
Berard,  P.  H. :   Fistules  urinaires.     Diet,  de  med.,  Paris,  1840,  xxii,  64. 
Binnie,  J.  F.:   Development  of  the  Urachus.     Jour.  Amer.  Med.  Assoc,  1906,  xlvii,  109. 
Cabell,  R.  G.:  Amer.  Jour.  Med.  Sci.,  Philadelphia,  1849,  n.  s.,  xv,  313. 
Charles,  J.  J.:   Treatment  of  Patent  Urachus.     Brit.  Med.  Jour.,  1875,  ii,  486. 
Delageniere,  H. :    Traitement  de  l'ouraque  dilate  et  fistuleux  par  la  resection  et  la  suture.     Une 

observation.     Arch,  provinciales  de  chir.,  1892,  i,  222. 
Draudt,  M.:    Beitrag  zur  Kenntnis  der  Urachusanomalien.     Deutsche  Zeitschr.  f.  Chir.,  1907, 

lxxxvii,  487. 
Dupuytren  and  Roux :  Un  ouraque  ouvert.     (Cited  by  Gueniot.) 

Erdmann,  J.  F. :  A  Patent  Urachus  in  a  Child  Four  Years  Old.     Pediatrics,  190S,  xx,  356. 
Florentin,  P.:    Fongus  de  l'ombilic   chez  le  nouveau-ne  et    chez  l'enfant.     These  de    Nancy, 

1908-09,  No.  22. 
Freer,  J.  A.:   Annals  of  Surgery,  1887,  v,  107. 
French,  J.  G.:   A  Case  of  Fleshy  Tumor  of  the  Lmibilicus  with  Patent  Urachus.     The  Lancet, 

1882,  i,  60. 
Goupil:   Sur  un  vice  de  conformation  singuliere.     Jour,  de  med.  de  Paris,  1756,  v,  108. 
Graf,  Fritz:   U/rachusfisteln  und  ihre  Behandlung.     Inaug.  Diss.,  Berlin,  1896. 
Griffith,  F.:   Possibly  a  Patent  Urachus.     (Vaughan's  article.) 

Gueniot,  R.:   Des  fistules  urinaires  de  l'ombilic  dues  a.  la  persistance  de  l'ouraque,  et  du  traite- 
ment qui  leur  est  applicable.     Bull,  de  therapeutique,  1872,  lxxxiii,  299;   348. 
Haran:  La  pratique  des  accouchement s,  i,  38.     (Quoted  by  Simon.) 
Heflin,  H.  T.:   Personal  communication. 

Hind,  W.:  Diseases  of  the  L"rachus  and  Lmibilicus.     Brit.  Med.  Jour.,  London,  1902,  ii,  242. 
Hue,  F.:   Persistance  du  canal  de  l'ouraque;  fistule  ombilicale.     La  Normandie  medicale,  1905, 

xx,  311. 
Huggins,  R.  B.:  Personal  communication. 
Imbert,  L.:  See  Vaughan's  article. 

Jacoby,  M.:  Zur  Casuistik  der  Nabelfisteln.     Berlin,  klin.  Wochenschr.,  1877,  xiv,  202. 
Jahn,  A.:   Beit  rage  z.  klin.  Chir.,  Tubingen,  1900,  xxvi,  323. 
Kennedy,  A.:  A  Patent  L'rachus.     Brit.  Med.  Jour.,  London,  1899,  i,  1396. 
Lannelongue:    In  cas  de  faux  penis  ombilical.      Lecons  de  clinique  chirurgicale,  Paris,  1905, 

388. 
Ledderhose,  G.:  Chirurgische  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Lexer,  E.:   L'eber  die  Behandlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  1898,  lvii,  73. 
Lugeol:    Fistule  urinaire  ombilicale  par  persistance  de  l'ouraque.     Jour,  de  med.  de  Bordeaux, 

1879-80,  ix,  3. 
Marx:   Enfant  de  vingt-trois  mois  et  demi,  qui  rendait  Purine  en  partie  par  la  verge  et  en  partie 

par  l'ouverture  ombiheale  de  l'ouraque.     Repertoire  general  d'anatomie  et  de  physiologic 

pathologique,  1827,  iv,  120. 
Meyer:    Offenbleiben  des  U/rachus  nach  der  Geburt.     Casper's  Wochenschr.  f.  d.  gesammte 

Heilkunde,  1S44,  424. 
Monod:    Des  fistules   urinaires  ombilicales  dues  a  la  persistance  de  l'om-aque.     These  de  Paris, 

1899,  No.  62. 
Paget  and  Bowman:   Medico-Chir.  Trans.,  pub.  by  the  Royal  Med.  and  Chir.  Soc,  London,  1850, 

2.  ser.,  xv,  293. 
34 


514  THE    UMBILICUS    AND    ITS    DISEASES. 

Paget  and  Bowman:  On  an  Operation  for  Pervious  Urachus.  Medico-Chirurgical  Trans.,  Lon- 
don, 1861,  xliv,  13. 

Pauchet,  V.:  Fistule  ombilico-vesicale.  Resection  sous-peritoneale  de  l'ouraque  et  d'une  poche 
urineuse  retro-ombilicale,  guerison.  Bull,  et  Mem.  de  la  Soc.  de  chir.  de  Paris,  1902,  xxviii, 
785. 

Penny,  W.  J.:  Bristol  Medico-Chirurgical  Jour.,  1888,  vi,  36. 

Petit,  J.  L. :  Traite  des  maladies  chirurg.,  chap.  xi.     Oeuvres  completes,  Limoges,  1837,  799. 

Pierre:  Bull.  Soc.  de  med.  de  Rouen,  1888,  2e  serie,  ii,  32. 

Preston,  W.:  Med.  Record,  New  York,  1898,  liv,  315. 

Rose,  A.:  A  Case  of  Congenital  Vesico-umbilical  Fistula,  Patent  Urachus.  Med.  Rec,  1877, 
xii,  516. 

Simon,  C:  Quels  sont  les  phenomenes  et  le  traitement  des  fistules  urinaires  ombilicales?  These 
de  Paris,  1843,  No.  80. 

Smit,  J.  A.  R.:  Abstract  from  Zentralbl.  f.  Gyn.,  1904,  Nr.  41. 

Smith,  T.:  An  Open  Urachus.     Med.  Times,  London,  1863,  new  series,  i,  320. 

Stadfeldt,  A. :  Bidrag  til  Laren  om  den  medfodte  Vesiko-umbilikalfistel  (Urachus- fisteln)  og  dens 
Behandling.     Nordiskt  Mediciniskt  Arkiv,  Stockholm,  1871,  iii,  No.  23. 

Starr,  T.  H.:  Escape  of  Urine  at  the  Umbilicus.     Med.  Gaz.,  1844,  xxxiii,  484. 

Stevens,  B.  C. :  The  Radical  Cure  of  a  Patent  Urachus.     The  Lancet,  London,  1904,  ii,  584. 

Stierlin,  R.:  Zur  Casuistik  angeborener  Nabelfisteln.  Deutsche  med.  Wochenschr.,  1897,  xxiii, 
188. 

Stites,  T.  H.:  Patulous  Urachus  in  a  Child  of  Nine  Months.  Amer.  Medicine,  Philadelphia, 
1903,  vi,  136. 

Tuholske,  H.:  A  Patent  Urachus  That  Closed  in  the  Fourth  Year  and  Began  Again  at  Forty- 
eight.     St.  Louis  Med.  Review,  February  11,  1905.     (From  Vaughan's  article.) 

Vander  Veer,  A. :  Congenital  Sinus  of  the  Urachus.     Med.  and  Surg.  Reporter,  1889,  lxi,  661. 

Vaughan,  G.  T.:  Trans.  Amer.  Surg.  Assoc,  1905,  xxiii,  273. 

Velpeau:  Cited  by  Gueniot. 

Waller,  C.  B.:  Patent  Urachus  in  a  Child  Five  Months  Old.  Operation.  Recovery.  Med. 
Bull.,  Philadelphia,  1885,  vii,  371. 

Willard,  De  Forest:  Med.  News,  Philadelphia,  1888,  liii,  710. 

Wolff,  C.  C. :  Beitrag  zur  Lehre  von  den  Urachuscysten.     Inaug.  Diss.,  Marburg,  1873. 

Yates,  W.  S.:  Phila.  Med.  Jour.,  1902,  x,  173. 


CHAPTER  XXX. 


REMNANTS  OF  THE  URACHUS. 


Historic  sketch. 

Observations  of  Luschka. 

Observations  of  Wutz. 

Remnants  of  the  urachus  noted  in  various  animals. 

In  the  chapter  on  Embryology  (p.  16)  we  have  seen  that  the  urachus  develops 
primarily  from  the  yolk-sac  and  that  it  passes  from  the  bladder  to  the  umbilicus. 
We  have  also  learned  that,  although  in  the  majority  of  embryos  it  finally  forms  a 
fibrous  cord,  it  nevertheless  shows  an  inherent  tendency  to  remain  patent  at  certain 
points  and  that  the  patent  areas 
are  recognized  as  spindle-like 
dilatations  occurring  here  and 
there  in  the  otherwise  imper- 
vious cord. 

Mery,  in  1700,  described  two 
twin  female  fetuses.  There  was 
only  one  placenta,  but  each  fetus 
had  its  cord.  In  each  the  um- 
bilicus formed  a  kind  of  cushion 
elevated  from  one-quarter  to 
one-third  of  an  inch  from  the 
surface  of  the  abdomen.  In 
the  center  of  each  umbilicus 
was  a  hole.  The  colon  ended 
at  the  edge  of  the  umbilicus 
and  formed  an  anus  for  the 
fetus.  The  fundus  of  the  blad- 
der was  also  open,  forming  a 
trough  which  terminated  at  the 
umbilicus. 

On  page  45  of  his  book  on 
"  Einige  Krankheiten  der  Nieren 
und  Harnblase,"  published  in 
Berlin  in  1800,  Walter  briefly 
describes  the  case  shown  in  Fig. 
222.  He  said  very  little  is  known 
about  remnants  of  the  urachus. 
He  further  said  that  Noreen,  a 

Swede,  in  a  Gottingen  dissertation  (1749),  mentioned  the  subject  under  the  title 
"De  mutatione  luminum  in  vasis  hominis  nascentis,  in  specie  de  uracho.'"  Noreen 
was  probably  the  first  person  to  write  somewhat  fully  concerning  dilatation  of  the 

515 


Fig.  222. — A  Pabtially  Patent  Urachus.  (After  F.  A.  Walter.) 
A,  the  right  ureter;  B,  the  left  ureter;  C,  represents  the  posi- 
tion of  the  longitudinal  muscle-fibers,  which  have  been  dissected 
back;  F,  F,  indicate  the  transverse  muscle-fibers ;  G,  the  tough  sub- 
mucosal H,  H,  bay-like  dilatations  of  the  urachus;  /,  indicates  the 
prostate ;  K,  the  nearest  portion  of  the  urethra.  The  specimen  was 
from  a  boy  twelve  years  of  age. 


516  THE    UMBILICUS    AND    ITS    DISEASES. 

urachus.  He  believed  that  the  urachus  remained  open  only  during  childhood;  that 
after  birth  the  canal  closed  and  was  transformed  into  a  solid  cord. 

Civiale.  in  1823,  saw  a  cadaver  from  which  the  intestine  had  been  lifted  out,  but 
the  pelvic  organs  were  intact.  The  bladder  made  a  prominent  termination  above, 
by  a  cylindric  prolongation  which  had  been  cut  across  several  lines  above  the  blad- 
der proper.  The  opening  permitted  the  introduction  of  a  finger  into  the  bladder 
and  corresponded  exactly  with  the  insertion  of  the  urachus.  It  was  smooth,  round- 
ish, and  surrounded  by  a  sort  of  muscle. 

For  many  years  a  controversy  went  on  as  to  the  permeability  of  the  urachus 
after  birth.  C.  Simon,  in  his  thesis  published  in  1843,  says  that  Harvey,  Noreen, 
Haller,  and  others  had  noted,  in  children  born  before  the  normal  time,  a  cavity  in 
the  urachus  extending  more  or  less  in  the  direction  of  the  umbilicus.  Into  this  it 
was  possible  to  introduce  a  bristle  or  to  inject  mercury.  These  dilatations  were, 
however,  confined  to  children  born  prematurely. 

Simon  refers  to  a  case  observed  by  Albinus.  The  patient  was  a  young  man. 
The  urachus  was  hollow  and  opened  into  the  bladder.  Albinus  held  that  it  was  by 
no  means  rare  to  find  the  urachus  in  a  permeable  condition  in  adults. 

According  to  Simon,  Verdries,  Beudt,  and  Haller  had  reported  examples  of  the 
same  character,  and  Haller  in  the  cadaver  of  an  adult  found  the  urachus  permeable 
and  was  able  to  introduce  a  bristle  into  it. 

Simon  mentions  cases  reported  by  Littre  and  Civiale,  and  refers  to  a  case 
recorded  by  Boehmer  in  his  thesis,  "Deuracho  humano."  Boehmer's  patient  was 
a  man  aged  forty,  who  died  of  an  "inflammation  in  the  chest."  At  autopsy,  when 
water  was  injected  into  the  bladder,  the  urachus  swelled  up  and  became  prominent. 

Probably  the  most  important  article  that  we  possess  is  that  of  Luschka,  pub- 
lished in  1862. 

Luschka  deals  with  the  so-called  obliterated  urachus  or  median  suspensory  liga- 
ment of  the  bladder  in  adults  under  normal  conditions.  He  says  there  is  no  doubt 
that  in  embryonic  life  the  urachus  remains  patent  as  far  as  the  umbilicus,  and  that  it 
communicates  with  the  bladder.  He  says  that  the  views  vary  widely  concerning  its 
relationship,  when  the  body  is  fully  developed,  and  that  the  differences  mainly  have 
to  do  with  the  question  whether  in  the  adult  this  cord  is  hollow  or  solid.  He  says 
that  the  majority  of  writers  agree  that  it  is  solid. 

Luschka  refers  to  the  observations  of  Walter.  This  author  thought  that,  as  a 
rule,  there  was  a  persistence  of  the  patent  urachus  and  that  the  canal  was  fre- 
quently filled  with  a  reddish  fluid.  On  the  other  hand  Noreen  (De  mutatione 
luminum  in  vasis,  etc..  in  specie  de  uracho,  1749)  held  the  opposite  view,  although 
in  one  instance  in  an  adult  he  was  able  to  pass  a  bristle  for  two  inches  into  the 
urachus.  The  views  of  Portal  (Memoires  de  Paris,  1769)  and  Meckel  (Handbuch 
der  menschlichen  Anatomic  Bd.  iv,  S.  474)  coincided  with  those  of  Noreen. 

Luschka  says  that  from  the  top  of  the  bladder  there  pass  a  number  of  bundles 
of  the  deep  detrusor  muscle  of  the  bladder.  These  extend  upward  for  a  certain 
distance  (Fig.  223).  The  muscle  gradually  loses  itself  in  a  thick,  pale  yellow  tissue 
which  consists  chiefly  of  elastic  fibers  and  which  really  is  the  tendon  of  the  smooth 
muscle  bundle.  Luschka  says  that,  as  a  rule,  this  bundle  can  readily  be  followed 
in  its  course  upward,  and  that  it  gradually  diminishes  in  thickness  and  ends  in  the 
umbilical  scar.  Sometimes  remnants  of  this  tissue  of  the  cord  pass  upward  to  the 
round  ligament  of  the  liver.     More  frequently,  however,  the  median  vesical  ligament 


REMNANTS    OF    THE    URACHUS. 


517 


docs  not  reach  the  umbilicus,  but,  beginning  at  a  point  some  5  or  6  cm.  above  the 
summit   of  the  bladder,  terminates  in  a  number  of   tendon-like  threads,  which, 
usually  unsymmetrically,  unite  with  the  left  and  right  vesical  ligaments,  or  may 
merge  into  one  another,  forming  a  kind  of  network.     If  one  carefully  splits  the 
longitudinal  axis  of  the  urachus  from  the  summit  of  the  bladder,  he  will  in  some" 
cases  be  able  to  see  an  extension  of  the  bladder  mucosa  upward  as  a  tubular  pro- 
jection reaching  a  distance  of  2  mm.,  and  a  pin-point  opening  may  be  found  existing 
between  the  urachus  and  the  bladder.     Usually,  however,  only  a  small  depression  is 
noted  at  the  summit  of  the  bladder,  and  very  fre- 
quently even  this  may  be  lacking,  so  that  in  the  ex- 
amination of  the  free  surface  of  the  bladder  mucosa 
no  trace  of  the  original  communication  between  the 
urachus  and  the  bladder  is  visible.     In  these  cases 
the  beginning  portion  of  the  urachus  has  been  obliter- 
ated.    Such  a  complete  closure  of  the  canal,  however, 
says  Luschka,  is  usually  noted  only  for  a  short  dis- 
tance.    The  urachus  soon  shows  the  cavity  again  for 
a  length  of  from  5  to  7  cm.,  or  sometimes  more.     The 
urachus,  however,  becomes  thinner  and  thinner,  and, 
as   a  rule,  varies   from   0.5  to   1  mm.  in  breadth. 
Luschka  says  that  in  the  adult  the  cavit}T  of  the 
urachus  in  the  median  vesical  ligament  has  a  mani- 
fold tortuous  course  with  numerous  large  and  small 
round  bays  running  off  from  it,  giving  it  a  nodular 
appearance,  and  occasionally  a  configuration  sugges- 
tive of  the  acinous  type  of  glands  (Fig.  224) .     These 
dilatations  sometimes  involve  the  entire  circumfer- 
ence of  the  tube,  but  more  often  are  lateral.     In  such 
cases  they  may  have  a  broad  base  or  be  more  or  less 
pedunculated.     Luschka  says  that  he  has  time  and 
again  noted  that  some  of  these  dilatations  have  grown 
as  pipe-like  branches  in  the  length  of  the  duct.     Some 
of  the  dilatations  in  the  course  of  time  are  nipped  off, 
and  as  a  result  of  further  growth  develop  into  cysts 
(Fig.  225). 

The  early  stage  of  cyst  formation  occurring  from 
metamorphosis  of  the  urachus  is  produced  very  fre- 
quently as  a  result  of  the  urachus  remaining  open  only 
at  isolated  points.     The  cysts  may  vary  in  size.     As 

a  rule,  they  are  so  small  that  they  are  recognized  only  when  studied  between  cover- 
glasses.  They  may,  however,  be  as  large  as  millet-seeds  or  reach  the  size  of  a  pea. 
They  may  be  isolated,  but  are  sometimes  present  in  large  numbers,  and  more  or  less 
closely  packed  together,  so  that  they  present  tumors  resembling  bunches  of  grapes. 

Luschka  says  that  he  has  not  had  any  individual  experience  with  cysts  of  the 
urachus,  and  knows  of  no  observations  by  others,  but  he  has  not  the  slightest  doubt 
that  large  cystic  tumors  of  the  anterior  abdominal  wall  needing  surgical  interference 
develop  and  that  these  tumors  have  originated  from  the  urachus. 

He  suggests  that,  if  one  wishes  to  study  the  cavity  formation  of  the  interior  of 


Fig.  223.— A  Patext  Urachus.     (Af- 
ter H.  Luschka.)      (Natural  size; 
from  a  man  fifty  years  old.) 
The  outer  side  of  the  upper  end 
of  the  bladder  mucosa  (a)  has  been 
freed  from  the  muscle  (6) ,  and  this  has 
been  turned  outward.     The  muscular 
portion  (c)  and  the  tendinous  portion 
(d)    of   the  median  vesical  ligament 
have  been  dissected  free  and  turned 
back.     In  this  way  the  urachus  has 
been  exposed  and  here  and  there  shows 
marked  nodular  dilatations  (/,  /,  /). 


518 


THE    UMBILICUS    AND    ITS    DISEASES. 


i 


The  fluid  is  usually 


< 


X 


^ 


r 


f 


the  median  vesical  ligament,  it  is  necessary  to  cut  it  out  in  sections,  treat  it  with 

acetic  acid,  and  make  firm  pressure  between  glass  plates.  The  structures  can  then 
be  gradually  dissected  out.  He  then  goes  on  to  describe  the 
ground  membrane,  the  layer  of  fibers,  and  finally  the  epithe- 
lium of  the  urachus.  In  speaking  of  the  epithelium  he  says 
that  where  the  canal  in  the  adult  is  well  preserved,  one  can 
scrape  away  the  thick  layer,  which  is  similar  to  the  so-called 
transitional  epithelium  noted  in  the  bladder,  ureters,  renal 
pyramids,  and  the  pelves  of  the  kidneys.  All  possible  forms 
of  these  cells  can  be  noted.  Some  are  round,  others  poly- 
gonal, some  are  branched,  and  some  resemble  cylindric  epi- 
thelium. 

The  contents  of  the  urachus  vary, 
pale  yellow,  thin,  and  translucent. 
It  may,  however,  be  cloudy,  brown, 
or  reddish  in  color.  It  contains  a 
large  number  of  cells  of  the  type 
above  described.  There  are  also 
numerous  fat-globules  and  not  in- 
frequently corpora  amylacea.  In 
the  dilatations  and  in  the  isolated 
cysts  the  contents  are  frequently 
sticky  and  dirty  brown.  Scattered 
throughout  the  fluid  are  bodies 
which  have  a  marked  resemblance 
to  prostatic  concretions. 

Veiel,  a  pupil  of  Luschka,  pub- 
lished a  thesis  on  the  urachus  in 
1862.  He  gave  a  very  extensive 
review  of  the  literature,  and  referred 
to  the  patent  urachus  in  the  calf  and 
pig.  He  also  reported  (Case  3)  an 
observation  on  a  man  twenty-four 

years  of  age.     The  urachus  was  4.1  cm.  long,  tortuous,  and 

formed  pearl-like  dilatations.    These  dilatations  were  partly 

central,  partly  eccentric,  varied  from  1  to  2  mm.  in  breadth, 

and  contained  a  3rellowish,  cloudy  fluid.     The  largest  was 

situated  just  above  the  bladder.     When  the  urachus  was 

placed  between  glass  plates,  the  fluid  could  be  forced  from 

one  dilatation  into  the  next. 

Hoffmann,   in   1870,   when   considering  the  pathologic 

changes  in  the  urinary  tract,  referred  to  the  early  work  of 

Walter.     He  says  that  Walter  sought  to  prove  that  the 

urachus  under  normal  conditions  in  both  sexes  remained  as 

an  open  canal  into  which  one  could  introduce  a  fine  sound 

and  pass  it  to  the  bladder.     This  view  was  not  accepted,  and  most  of  the  later  anat- 
omists concluded  that  the  urachus  in  the  grown  person  was  completely  obliterated. 

Hoffmann  refers  to  the  work  of  Luschka,  in  which  it  was  demonstrated  that  in  most 


Fig.  224. — A  Portion-  of  a 
Urachcs  Seven  Times 
Enlarged,  with  Nu- 
merous Large  and 
Small  Dilatations. 
From  a  man  twenty- 
seven  years  old.  (After 
H.  Luschka.) 


Fig.  225. — Portion  of  a 
Urachus  Ten  Times 
Enlarged.  (After  H. 
Luschka.) 

This  here  and  there 
shows  a  tortuous  course  as 
indicated  by  a.  At  certain 
points  (6,  b)  are  dilatations. 
One  of  these  dilatations  (c) 
has  already  become  com- 
pletely nipped  off,  forming 
a  cyst. 


REMNANTS    OF    THE    URACHUS.  519 

of  the  cases  the  urachus  is  patent  for  a  certain  distance,  even  if  it  does  not  always 
communicate  with  the  bladder.  He  also  drew  attention  to  the  fact  that  Luschka 
agreed  with  Walter  in  holding  that  the  urachus  is  lined  with  mucosa.  With  Luschka's 
statement  that  the  caliber  of  the  urachus  is  not  uniform  but  tortuous,  and  that  it 
has  numerous  large  and  small  bays  running  out  from  it  and  giving  rise  to  a  nodular 
appearance,  reminding  one  somewhat  of  an  acinous  gland,  Hoffmann  in  general 
agreed. 

Gruget,  in  1872,  published  a  very  interesting  thesis  on  urinary  umbilical  fistula? 
due  to  persistence  of  the  urachus.  He  examined  in  all  82  bodies,  and  only  twice  did 
he  find  the  urachus  permeable. 

Case  1  .  —  A  human  embryo,  two  and  a  half  months  old,  was  received  by 
Dr.  Gueniot.  It  weighed  20  grams.  The  distance  from  the  pubes  to  the  umbilicus 
was  7  mm.  A  portion  of  the  abdominal  wall  was  gelatinous.  The  walls  of  the 
bladder  were  transparent,  and  the  bladder  contained  a  few  drops  of  a  colorless 
liquid.  When  the  bladder  was  opened  a  fine  probe  could  be  carried  into  the  urachus, 
which  was  patent.  In  this  case  the  urachus  was  open  from  the  bladder  to  the 
umbilicus,  and  was  continued  as  a  pervious  canal  out  into  the  cord  for  at  least  3  cm. 

[This  is  occasionally  noted  in  a  human  embryo  at  this  age — 7.5  cm.] 

C  a  s  e  2  was  that  of  a  female  fetus  born  living  at  the  end  of  the  fifth  month 
and  dying  twenty  minutes  after  birth.  This  case  also  came  under  Dr.  Gueniot's 
observation.  The  urachus  was  obliterated  in  its  inferior  or  vesical  portion,  but 
open  in  its  upper  portion  and  also  out  into  the  cord,  where  it  again  became  obliter- 
ated, forming  a  filament.  Gruget,  from  his  studies,  came  to  the  conclusion  that 
persistence  of  the  urachus  is  very  rare.     His  article  is  very  carefully  written. 

Nicaise  assures  us  that  a  hollow  urachus  is  not  rare.  He  says  that  Haller 
demonstrated  this  condition  in  the  cadaver  of  an  adult,  and  that  he  had  seen  the 
urachus  large  enough  to  have  a  silk  thread  passed  through  it.  He  adds  that 
Harvey,  Moreau,  Verdries,  and  Beudt  had  described  examples  of  the  persistence 
of  the  urachus. 

Tillmanns  says  that  Meckel,  in  1809,  described  a  cystic  dilatation  of  the  urachus. 
Next  to  the  fundamental  work  of  Luschka  is  that  of  Wutz,  published  in  1883. 
Wutz  said  that  Peu,  in  his  book  on  Obstetrics,  in  1694,  speaks  of  a  tumor  the  size  of 
a  pigeon's  egg  situated  at  the  umbilicus  in  a  child  two  hours  old.  When  this  tumor 
was  opened,  urine  escaped. 

Wutz  refers  to  the  early  literature  on  the  urachus,  mentioning  the  names  of 
Blasius  (1674),  Littre  (1701),  Peyer  (1741),  Albinus  (1754),  Boehmer  (1764),  Portal 
(1769),  Walter  (1775),  Meckel  (1820),  and  finally  reviews  the  findings  of  Luschka. 

Wutz  (p.  390)  gives  a  description  of  his  own  work,  and  says  that  his  observations 
are  based  on  the  examination  of  74  bodies  of  various  ages,  including  males  and 
females. 

He  found  that  the  distance  from  the  top  of  the  bladder  to  the  lower  margin  of  the 
umbilicus  was  as  follows : 

In  the  young  and  new-born 3.1  cm. 

In  persons  from  seventeen  to  twenty-five  years 16.5  cm. 

"        "  "      twenty-five  to  seventy  years 18.7  cm. 

He  says  that  at  the  top  of  the  bladder  the  median  vesical  ligament  has  a  thickness 
of  from  2  to  2.5  mm.     He  then  takes  up  the  consideration  of  the  urachus,  and  draws 


520 


THE    UMBILICUS    AND    ITS    DISEASES. 


attention   to   the   fact    that    Suchannek,  in   his   investigations,  left   the  urachus 
in  hydrochloric  acid  for  two  days.     As  a  result,  the  musculature  and  the  con- 
nective tissue  were  then  so  soft  that  they  could  easily  be 
removed. 

Wutz,  after  using  a   1   per  cent  solution  of    sodium 
chlorid.  hardened  the  specimen  in  alcohol  and  then  stained 
it  with  Grenadier's  carmin,  picrocarmin,  or  hematoxylin. 
The  specimen  was  then  passed  through  oil  of  cloves  and 
mounted  in  Canada  balsam.     In  this  way  it  was  possible 
to  obtain  a  beautiful  low-power  picture  and  at  the  same 
time  study  the  specimens  under  the  higher  power.     Wutz 
says  that  after  careful  division  of  the  rather  tough  capsule 
the  transparent  urachus  is  reached  (Fig.  226).     His  exam- 
ination showed  that  the  commencing  portion  of  the  epithe- 
lial tube  is  frequently  embedded  in  the  musculature  of  the 
vertex  of  the  bladder  for  a  distance 
of  0.5  to  1  cm.     He  says  that  with- 
in the  thickness  of  the  bladder-wall 
the  urachus  often  runs  at  an  angle 
(Fig.  227) .     On  examination  of  the 
inner  surface  of  the  bladder  at  the 
point  where  the  urachus  begins,  in 
the  majority  of   cases  there  is  a 
funnel-like  depression,  and  at  the 
point  of  the  funnel  a  fine  opening.  , 

Fifty-one  (69  per  cent)  of  Wutz's 
cases  presented  an  opening  of  such  ."■ 

a  character,  into  which  a  bristle 
could  be  passed  for  0.3  to  0.5  mm. 
In  32  of  these  cases  this  could  be 
carried  upward  for  a  distance  of 
from  2  to  6  mm.,  while  in  19  it 
penetrated  from  1.1  to  4.8  cm. 
In  2  cases  out  of  74  (2.7  per 
cent)  the  surface  of  the  mucosa  was  smooth  and  indicated 
no  trace  of  a  previous  communication  between  the  urachus 
and  bladder.  In  the  remaining  21  cases  there  was  a  very 
perceptible  groove  at  the  entrance  of  the  urachal  canal.  In 
these  cases  it  was.  however,  impossible  to  pass  a  sound  up- 
ward, although  it  could  be  passed  from  above  downward  for 
a  certain  distance.  In  several  of  the  cases  in  the  first  group, 
in  which  the  sound  could  be  passed  from  the  bladder,  a  cer- 
tain degree  of  obstruction  was  noted  at  the  entrance  of  the 
canal.  In  other  cases  Wutz  gathered  the  impression  that 
the  urachal  opening  was  guarded  by  a  valve-like  structure 

apparently  supplied  by  a  transverse  fold.  He  says  that,  under  normal  conditions, 
the  passage  of  urine  through  the  urachus  does  not  occur,  notwithstanding  the  exist- 
ing communication.     In  cases  of  marked  dilatation  of  the  bladder  due  to  prostatic 


B 

Fig.  226.  —  Cysts  of  the 
Urachus  Arranged 
Like  a  String  of 
Pearls,  from  Case  17. 
(After  J.  B.  Wutz's  Plate 
xii,  Fig.  C.) 

The  cysts  are  near  to  the 
bladder.  There  are  three  of 
uniform  size,  with  two  smaller 
ones  between  them.  In  the 
upper  portion  of  the  urachus 
are  several  small,  spindle- 
shaped  dilatations.  V  is  the 
bladder.  B  is  a  bristle  pass- 
ing up  into  the  urachus. 


.Ear 


y 


■-- 


Fig.  227. — Spindle-shaped 
Dilatations  of  the 
Urachus.  (After  J.  B. 
Wutz,  Plate  xi,  Fig.  E.) 
Case  22. 

V  is  the  bladder;  Eur, 
the  urachus.  Near  the  blad- 
der there  is  a  small  dilata- 
tion, then  a  spindle-shaped 
dilatation,  and  a  little  far- 
ther up  the  largest  spindle- 
shaped  cyst. 


REMNANTS    OF    THE    URACHUS.  521 

hypertrophy  the  dilatation  of  the  canal  was  never  noticed  by  him,  and  in  the  new- 
born the  passage  of  a  bristle  was  only  occasionally  possible. 

Wutz  measured  microscopically  the  epithelial  tube  and  found  that  the  average 
length  in  the  new-born  was  about  1.6  cm.,  in  adults,  6.7  cm.,  and  in  one  case  it  was 
7.7  cm.  He  says  that  the  greatest  diameter  (1.5  to  2  mm.)  of  the  urachal  tube  is 
at  or  near  the  bladder.  In  the  region  of  the  umbilicus  it  had  become  smaller,  being 
0.5  mm.  The  cells  forming  the  lining  of  the  urachus  were  large,  oval,  and  showed 
large  nuclei.  Some  were  long  and  had  tails,  and  there  were  many  branching,  flat 
epithelial  cells.  As  a  rule,  there  were  three  layers  of  epithelium.  In  the  upper 
portion  there  were  sometimes  two  layers,  but  finally  only  one  layer.  The  trans- 
verse section  of  the  urachus  was  usually  not  round,  but  flattened  or  elliptic,  and  not 
infrequently  wavy.  The  outer  longitudinal  layer  of  muscle  Wutz  found  to  be  con- 
stant, and  in  all  cases  it  extended  beyond  the  epithelial  tube  above. 

Wutz's  summary  is  as  follows: 

1.  The  epithelial  tube  of  the  median  vesical  ligament  in  most  cases  in  its  lower 
portion  can  be  sounded  from  the  bladder.  In  other  words,  a  probe  can  be  passed 
into  it  from  the  bladder. 

2.  At  the  entrance  of  the  urachus  there  is  a  transverse  fold  which  makes  the 
entrance  of  the  sound  more  difficult  and  hinders  the  passage  of  fluid  into  the  urachus. 
[This  obstruction  has  of  late  years  been  known  as  Wutz's  valve. — T.  S.  C] 

3.  Toward  the  upper  end  of  the  epithelial  tube  the  diameter  of  the  urachus 
diminishes  in  both  its  muscular  and  epithelial  portions. 

4.vThe  musculature  under  all  conditions  extends  farther  upward  than  the 
epithelial  tube. 

5.  The  beginning  of  the  tendinous  character  of  the  median  vesical  ligament 
corresponds  somewhat  constantly  in  children  to  one-half,  and  in  adults  to  one- 
third,  of  the  distance  between  the  umbilicus  and  the  summit  of  the  bladder. 

Monocl,  in  1899,  published  an  interesting  thesis  of  over  200  pages  on  Urinary 
Umbilical  Fistulse  Due  to  Persistence  of  the  Urachus.  In  the  historic  portion  of  his 
publication  he  refers  to  the  observations  of  Meckel,  Cuvier,  Pokels,  Velpeau,  and 
Robin.  Monod  says  that  he  does  not  consider  the  persistence  of  the  urachus  a 
malformation  as  rare  as  was  believed  by  Gueniot  and  his  pupil  Gruget,  but  agrees 
with  Forgue  and  Morer  and  Trogneux  that  this  malformation  is  not  very  frequent 
without  being  exceptional. 

Meriel,  in  1901,  gave  a  very  good  resume  of  the  literature,  and  Vaughan,  in 
1905,  presented  an  interesting  paper  on  the  subject  before  the  American  Surgical 
Association. 

Binnie,  in  1906,  published  a  paper  on  the  development  of  the  urachus  and  gave 
the  results  of  Mr.  Clendening's  investigations.  Sixteen  cadavers  and  7  fetuses  were 
examined,  with  the  following  results : 

1.  In  seven  adults  and  six  fetuses  the  bladder  showed  a  distinct  diverticulum 
from  1  to  2  cm.  deep,  at  the  point  where  the  urachus  is  usually  attached. 

2.  In  one  adult  there  was  a  slight  projection  instead  of  a  diverticulum. 

3.  In  eight  adults  and  one  fetus  the  dome  of  the  bladder  was  smooth. 

4.  In  none  of  the  cases  did  Clendening  find  lacunae  lined  with  epithelium  in  the 
urachus. 

5.  The  average  adult  urachus  was  12  cm.  long  and  1.5  [mm.]  wide. 

6.  The  urachus  was  usually  adherent  to  the  abdominal  wall,  but  in  one  patient 


522  THE    UMBILICUS    AND    ITS    DISEASES. 

(a  diabetic  with  frequent  retention  of  urine)  it  was  not  close  to  the  parietes,  but 
lay  between  loops  of  the  small  intestine. 

7.  In  all  cases  the  urachus  was  well  supplied  with  vessels. 

From  this  review  of  the  literature  it  is  evident  that  the  urachus  in  a  certain 
number  of  cases  remains  patent  throughout.  Hence  under  such  circumstances, 
as  soon  as  the  cord  comes  away  a  few  days  after  birth,  a  urinary  fistula  exists 
at  the  umbilicus. 

In  other  cases  portions  of  the  urachus  may  remain  open.  The  vesical  end  of  the 
urachus  may  be  connected  with  the  bladder,  but  more  frequently  small,  cyst-like 
dilatations  are  found  in  the  course  of  the  obliterated  urachal  cord.  These  may 
later  dilate,  giving  rise  to  urachal  cysts.  In  some  instances  they  become  infected, 
and  an  abscess  develops  in  the  anterior  abdominal  wall,  between  the  recti  muscles 
and  the  peritoneum  of  the  anterior  wall  of  the  abdomen.  In  those  patients  in  whom 
remnants  of  the  urachus  exist,  any  interference  with  the  easy  passage  of  urine  from 
the  urethra  is  liable  to  be  followed  by  a  reopening  of  the  urachus,  with  an  escape 
of  urine  from  the  umbilicus.  Such  a  condition  may  be  due  to  a  vesical  calculus 
plugging  the  inner  urethral  orifice,  to  a  urethral  stricture  or  to  blocking  by  an 
enlarged  prostate.  In  quite  a  number  of  cases  cystitis  with  its  consequent  vesical 
tenesmus  has  been  followed  by  infection  of  the  urachus  and  the  development  of  a 
urinary  umbilical  fistula. 

In  the  succeeding  chapters  I  shall  consider  in  detail  the  literature  on  abnormali- 
ties due  to  remnants  of  the  urachus. 


LITERATURE  CONSULTED  ON  REMNANTS  OF  THE  URACHUS. 

(See  also  the  literature  of  the  following  chapters.) 

Binnie,  J.  F.:   Development  of  the  Urachus.     Jour.  Amer.  Med.  Assoc,  1906,  ii,  109. 

Civiale,  J.:  Traite  de  l'affection  calculeuse,  Paris,  1838,  258. 

Gruget,  L.:    Des  fistules  urinaires  ombilicales  qui  se  produisent  par  l'ouraque  reste  ou  redevenu 

permeable.     These  de  Paris,  1872,  No.  422. 
Hoffmann,   C.   E.   E.:    Zur  pathologisch-anatomischen  Veranderung  des   Harnstrangs.     Arch. 

der  Heilkunde,  1870,  xi,  373. 
Luschka,  H.:   Ueber  den  Bau  des  menschlichen  Harnstranges.     Arch.  f.  path.  Anat.  u.  Physiol. 

u.  f.  klin.  Medizin,  1862,  xxiii,  1. 
Meriel:  Les  derives pathologiques  de  l'ouraque.     Gaz.  des  hopitaux,  Paris,  1901,  lxxiv,  181. 
Mery:  Hist.  Acad,  roy  de  sc.  (de  Paris),  Amsterdam,  1700,  53. 
Monod,  J. :  Des  fistules  urinaires  ombilicales  dues  a  la  persistance  de  l'ouraque.     These  de  Paris, 

1899,  No.  62. 
Nicaise:  Ombilic.     Diet,  encyclopedique  des  sci.  medicales,  Paris,  1881,  2.  ser.,  xv,  140. 
Simon,  C.:   Quels  sont  les  phenomenes  et  le  traitement  des  fistules  urinaires  ombilicales.     These 

de  Paris,  1843,  No.  80. 
Tillmanns,  H.:    Ueber  angeborenen   Prolapsus  von   Magenschleimhaut   durch  den  Nabelring 

(Ectopia  ventriculi)   und  iiber  sonstige  Geschwulste  und  Fisteln  des  Nabels.     Deutsche 

Zeitschr.  f.  Chir.,  1882-83,  xviii,  161. 
Vaughan,  G.  T.:   Patent  Urachus.     Review  of  the  Cases  Reported.     Operation  on  a  Case  Com- 
plicated with  Stones  in  the  Kidneys.     A  Note  on  Tumors  and  Cysts  of  the  Urachus.     Trans. 

Amer.  Surg.  Assoc,   1905,  xxiii,  273. 
Veiel,  E.:    Die  Metamorphose  des  Urachus.     Diss.,  Tubingen,  1862. 
Walter,  F.  A.:   Einige  Krankheiten  der  Nieren  und  Harnblase,  Berlin,  1800. 
Walters,  F.  R.:   Umbilical  Pocket.     Brit.  Med.  Jour.,  1893,  i,  173. 
Wutz,  J.  B.:  Ueber  Urachus  und  Urachuscysten.     Virchows  Arch.,  1883,  xcii,  387. 


REMNANTS    OF    THE    URACHUS.  523 

REMNANTS  OF  THE  URACHUS  NOTED  IN  VARIOUS  ANIMALS. 

I  have  made  no  attempt  to  cover  the  literature  on  this  subject,  but  while  study- 
ing the  urachal  remains  noted  in  the  human  being,  I  have  from  time  to  time  met 
with  references  to  partial  or  complete  urachal  remains  noted  in  animals. 

There  seems  to  be  little  doubt  that  urachal  remains  are  more  commonly  found 
in  the  horse  than  in  any  other  domestic  animal.  Gurlt,  in  1832,  in  speaking  of  the 
horse,  said:  "It  sometimes  happens  that  after  birth  the  bladder  with  the  urachus 
separates  from  the  umbilicus  and  closes  up,  but  a  vesical  portion  of  the  urachus  does 
not  disappear,  but  gradually  develops  into  an  open  chamber  as  large  as  the  bladder 
itself.  In  these  cases  we  have,  as  it  were,  two  bladders,  one  sitting  on  the  top  of  the 
other,  and  the  two  communicating  through  a  large  channel."  Gurlt  observed  this 
condition  in  a  grown  horse. 

O'Brien,  writing  in  1879,  quotes  Cheaureau:  "In  a  fetal  horse  the  bladder 
occupies  the  abdominal  cavity  as  far  as  the  umbilical  opening,  the  anterior  ex- 
tremity forming  a  veritable  neck.  At  birth  this  anterior  neck  separates  from  the 
urachus  and  is  transformed  into  a  cul-de-sac  which  is  gradually  withdrawn  into 
the  pelvis."  O'Brien,  while  dissecting  a  young  colt  dead  of  osteitis,  found  that 
the  bladder  extended  by  a  funnel-shaped  canal  to  the  umbilicus. 

Finch,  in  1903,  reported  a  case  of  pervious  urachus  in  a  colt.  The  colt  was  ten 
days  old  and  had  colicky  pains,  as  was  evidenced  by  his  uneasiness.  The  umbilicus 
was  much  enlarged  and  wet,  this  condition  being  evidently  due  to  the  presence  of  a 
pervious  urachus.  The  colt  apparently  had  pain  over  the  loins.  The  urine  was 
clear. 

Purgatives  and  soothing  applications  were  employed,  but  the  colt  died  in  a  few 
days.  The  autopsy  showed  that  a  portion  of  the  large  bowel  was  inflamed.  The 
umbilical  cord  was  thickened  and  contained  a  small  amount  of  thick,  creamy  pus. 
The  walls  of  the  bladder  were  thickened  and  inflamed.  Nothing  is  stated  in  the 
protocol  about  the  urachus. 

Salvisberg,  in  1902,  related  his  experience  with  urachal  fistulse  in  the  horse, 
and  outlined  his  method  of  handling  them.  He  says  that  when  the  cord  is  torn  off 
too  close  to  the  body  in  colts,  the  urachus  remains  open,  and  part  of  the  urine  escapes 
from  the  umbilicus.  The  urachus  in  colts  has  grown  fast  to  the  umbilical  ring; 
consequently  the  closure  of  the  ring  is  not  so  easy.  If  the  cord  of  every  colt  were 
properly  tied,  a  urinary  fistula  at  the  umbilicus  would  be  very  rare. 

Salvisberg  says  that  every  spring  he  operates  on  several  colts  with  urachal 
fistulse.     It  is  no  art  to  tie  the  cord  3  or  4  cm.  from  the  abdomen. 

From  three  to  fourteen  days  after  the  birth  of  the  colt  the  farmer  reports  the 
fistula.  The  urine  drops  from  the  umbilical  opening,  or  during  urination  a  certain 
amount  escapes  from  the  umbilicus. 

Where  a  stump  is  present,  the  surrounding  skin  shows  little  change,  the  urine 
being  carried  off,  as  it  were,  through  a  pipe.  Usually  the  opening  is  on  the  skin 
level  or  in  a  small  groove.  It  is  then  surrounded  by  a  zone  of  granulation  tissue. 
The  hair  is  wet  and  stuck  together.  An  area  around  the  umbilicus  is  swollen, 
and  has  scattered  over  it  many  ulcers ;  or  it  is  occupied  by  one  large  ulcer  from  which 
a  purulent  foul  discharge  comes. 

Salvisberg  used  silver  nitrate,  copper  sulphate,  etc.,  but  some  of  the  colts  died 
of  pyemia  or  polyarthritis.     The  use  of  a  purse-string  suture  proved  of  no  value. 


524  THE    UMBILICUS   AND    ITS    DISEASES. 

Dissecting  out  the  urachus  from  the  umbilicus  and  tying  was  fatal,  as  the  peri- 
toneum has  to  be  opened. 

Salvisberg  finally  decides  upon  the  following  procedure:  The  umbilical  region 
is  shaved  and  disinfected  and  injections  of  salt  solution  are  made  into  the  parts 
in  the  immediate  vicinity.  These  should  produce  small  elevations,  the  size  of 
hazelnuts,  all  around  the  opening;  two  or  three  rows  are  made.  The  surface  is 
then  covered  with  an  iodoform-collodion  dressing.  Frequently,  in  a  few  hours,  the 
elevations  disappear  and  a  uniform  swelling  closes  the  urachus.  Sodium  chlorid 
solution,  15  per  cent,  is  used.  To  this  a  few  drops  of  pure  carbolic  acid  are  added. 
The  results  appear  to  be  good. 

Swain,  in  the  Veterinary  Archives  for  1903,  when  referring  to  persistency  of  the 
urachus,  says:  "The  equine  family  seems  much  more  subject  to  this  abnormality 
than  the  bovine  or  other  domestic  animals,  and  the  breeds  of  draft-horses  are  more 
subject  than  the  finer  breeds;  the  male  foal  is  more  subject  to  this  persistence  than 
the  female." 

Bland-Sutton,  in  "Tumors,  Innocent  and  Malignant,"  1907,  says  that  he  had 
observed  urachal  cysts  in  the  horse. 

Recently,  while  conversing  with  my  old  friend  and  classmate,  Dr.  W.  N.  Barn- 
hardt,  about  urachal  remains,  he  told  me  that  for  years  he  had  been  interested  in 
this  subject,  and  that  he  had  observed  numerous  abnormalities  in  the  horse.  I 
asked  him  to  give  me  briefly  the  results  of  his  observations.  Under  date  of  April, 
1914,  he  writes: 

"Living  for  years  on  a  horse-breeder's  ranch,  I  developed  a  curiosity  as  to  the 
cause  of  death  of  foals.  Among  other  morbid  conditions  I  observed,  by  post- 
mortem examination,  a  patent  urachus  in  five  foals  that  had  died  within  four  days 
of  their  birth.  One  of  these  showed  a  red  thrombus  about  the  size  and  shape  of  a 
small  banana,  and  two  others  showed  infection  and  inflammation  within  the 
urachus.  In  four  of  them  urine  had  flowed  quite  freely  from  the  umbilicus.  In 
others  that  lived  and  attained  a  healthy  maturity  I  have  observed  an  occasional 
discharge  of  urine  at  the  umbilicus  in  the  first  few  days  after  birth." 

From  the  foregoing  it  is  clearly  evident  that  urachal  remains,  particularly 
umbilical  fistulae,  are  relatively  common  in  the  horse. 

Urachal  Remains  in  the  Cow  or  Steer.  —  Gurlt,  in  1831, 
when  referring  to  a  cyst-like  pouch  of  the  urachus  seated  on  the  top  of  the  bladder 
and  resembling  a  second  bladder  in  a  horse,  said  that  he  had  once  observed  a  similar 
condition  in  a  cow.  This  case  was  seen  in  consultation  with  a  veterinary  surgeon 
named  Naundorf. 

Veiel,  in  1862,  reported  several  cases.  In  the  examination  of  an  eleven-day-old 
steer  he  found  passing  from  the  top  of  the  bladder  a  urachus  which  could  be  traced 
for  5.6  cm.  as  a  tube.  It  was  6  mm.  broad  and  had  a  relatively  uniform  diameter. 
Veiel,  in  Case  3,  refers  to  a  sixteen-day-old  calf.  The  top  of  the  bladder  gradually 
diminished  in  size  and  passed  over  into  the  urachus,  which  was  open  as  far  as  the 
umbilicus. 

Bland-Sutton  has  observed  urachal  cysts  in  the  ox,  in  the  pig,  and  in  the  mole. 

Urachal  Remains  in  the  Pig.  —  In  a  sow  one  year  old,  Veiel 
observed  at  the  top  of  the  bladder  a  cord  7.3  cm.  long  and  about  2  mm.  broad.  On 
carefully  splitting  the  muscle  and  turning  it  back,  he  detected  a  small  lumen. 
This  was  uniform  in  diameter,  but  at  each  end  was  a  round  dilatation. 


REMNANTS    OF    THE    URACHUS.  525 

Hoffmann,  in  1870,  made  an  interesting  observation  on  cysts  of  the  urachus  in  a 
swine  embryo.  He  first  referred  to  an  observation  by  Meckel,  who  found  in  a 
swine  at  term  a  cyst  of  the  urachus,  one  inch  in  diameter,  situated  four  inches 
below  the  umbilicus.     At  either  end  it  was  attached  to  the  urachus. 

Hoffmann  said  that  in  1866  he  received  from  a  butcher  a  so-called  double 
urinary  bladder.  This  came  from  a  full-grown  pig  and  had  the  form  of  two  sacs 
of  the  same  size,  which  were  separated  from  one  another  by  a  narrowing  in  the 
middle.  When  distended,  both  halves  were  elongated  and  rounded,  and  it  looked 
as  if,  on  the  summit  of  the  portion  connected  with  the  urethra,  a  second  bladder 
was  situated.  In  the  distended  condition  the  lower  compartment  was  31  cm.  long 
and  22  cm.  in  diameter.  The  upper  one  was  25  cm.  long  and  had  a  breadth  of  24 
cm.  These  two  cavities  occupied  the  space  between  the  urethra  and  the  umbilicus. 
Over  its  entire  surface  was  a  peritoneal  covering.  At  the  umbilicus  the  upper  por- 
tion was  closed.  The  lumen  occupying  the  usually  obliterated  portion  of  the 
urachus  had  dilated,  forming  the  second  bladder. 

Sutton  observed  urachal  cysts  in  the  pig. 


LITERATURE  CONSULTED  ON  REMNANTS  OF  THE  URACHUS  IN  ANIMALS. 
Bland-Sutton,  J.:    Tumors,  Innocent  and  Malignant,  Chicago,  1907. 

Finch,  R.:  Case  of  Pervious  Urachus  (in  a  Colt).     Veterinary  Record,  London,  1902-03,  xv,  798. 
GurJt,  E.  F.:  Path.  Anat.  der  Haus-Saugethiere,  1831,  i,  213. 
Hoffmann,    C.   E.   E.:    Zur  pathologisch-anatomischen  Veranderung  des   Harnstrangs.     Arch. 

der  Heilkunde,  1870,  xi,  373. 
O'Brien,  J.  E.:    Pervious  Urachus,  Comparative  Anatomy.     The  Obstetric  Gazette,  Cincinnati, 

1879-80,  ii,  100. 
Salvisberg:    Die  Behandlung  der  Urachusfistel  beim  Fohlen.     Sehweizer  Arch.  f.  Thierheilkunde. 

1902,  xliv,  228. 
Swain,  S.  H.:   Persistency  of  the  U/rachus.     Jour.  Compar.  Med.  and  Veterinary  Archives,  1903. 

xxiv,  95. 
Veiel,  E.:  Die  Metamorphose  des  Urachus.     Diss.,  Tubingen,  1862. 


CHAPTER  XXXI. 

URACHAL  REMNANTS  PRODUCING   TUMORS  BETWEEN  THE  UMBIL- 
ICUS AND  SYMPHYSIS. 

Small  urachal  cysts;  Historic  sketch;  Report  of  cases. 
Personal  observations  on  small  cysts  of  the  urachus. 

Remnants  of  the  urachus  may  become  distended,  producing  small  or  large 
cysts,  which  may  or  may  not  become  infected.  Some  of  them  are  directly  con- 
nected with  the  bladder  or  with  the  umbilicus  or  with  both.  For  convenience  I 
have  made  the  following  tentative  classification.  Some  overlapping,  of  course,  is 
inevitable. 


(1)  Small  urachal  cysts. 

(2)  Large  urachal  cysts. 


Non-infected. 
Infected. 

(3)  Urachal  cavities  lying  between  the  symphysis  and  umbilicus  and  com- 
municating with  the  bladder  or  umbilicus  or  both. 


SMALL  URACHAL  CYSTS. 

Small  urachal  cysts  naturally  give  rise  to  no  clinical  symptoms,  hence  they  are 
recognized  only  when  the  abdomen  is  opened  for  some  intra-abdominal  lesion  or 
at  autopsy.  It  is  not  to  be  wondered  at,  therefore,  that  the  literature  on  the  sub- 
ject is  very  meager. 

As  has  been  said  before,  Luschka  concludes  that  large  cystic  tumors  of  the 
anterior  abdominal  wall  needing  surgical  interference  develop,  and  that  these 
tumors  originate  from  the  urachus. 

Veiel,  in  1862,  in  his  dissertation  on  the  Metamorphosis  of  the  Urachus,  cites 
the  findings  in  the  body  of  a  man  forty-five  years  of  age.  Passing  downward  from 
the  umbilicus  was  a  delicate  cord  1  mm.  broad.  About  3  cm.  above  the  bladder  it 
grew  larger,  so  that  at  the  top  of  the  viscus  it  was  1.2  cm.  thick.  At  this  point 
it  was  covered  with  a  thick  layer  of  bladder  muscle.  The  urachus  could  be  divided 
into  four  sections — the  lowest  (part  1),  which  was  open,  was  14  mm.  long.  In  the 
middle  it  was  somewhat  smaller,  but  at  each  end  it  was  2  mm.  thick.  Part  2  was 
7  mm.  long  and  was  closed  and  thread-like.  Part  3  was  8  mm.  long,  was  open,  and 
about  1  mm.  thick.  Part  4  was  closed  and  thread-like.  On  microscopic  examina- 
tion the  upper  open  portion  showed  moisture  and  had  a  lining  of  so-called  transi- 
tional epithelium.  After  the  specimen  had  been  treated  with  acetic  acid,  three  dila- 
tations of  the  canal  were  found.     These  contained  yellowish  concretions. 

Wutz,  in  1883,  after  reporting  his  Case  22,  in  which  the  urachal  cyst  contained 
a  firm,  stony,  hard,  yellowish  brown,  glistening  body,  described  the  following  case 
in  detail : 

Case   24.  —  The  specimen  was  from  a  man  twenty  years  old,  dead  of  peri- 

526 


SMALL    URACHAL    CYSTS.  527 

tonitis  following  a  perforated  appendix.  The  distance  from  the  umbilicus 
to  the  top  of  the  bladder  was  16  cm.  The  bladder  mucosa  in  the  vicinity  of 
the  trigonum  was  diffusely  reddened,  and  on  its  surface  were  a  few  blood  and  pus 
corpuscles.  The  bladder  was  small  and  drawn  out  to  a  point.  It  was  7.5  cm.  in 
length.  In  the  mucosa  of  the  vertex  the  opening  of  the  urachal  canal  had  a  diame- 
ter of  2  mm. ;  2.5  cm.  above  the  bladder  was  a  cyst  1.5  cm.  long,  0.8  cm.  broad,  and 
attached  to  the  side  of  the  urachus;  into  it  a  sound  could  be  passed  from  the 
urachus.  About  3  mm.  above  this  cyst  were  several  smaller  ones,  some  reaching 
the  size  of  a  pin-head.  Wutz  said  that  a  probe  could  be  passed  into  the  urachal 
canal  for  a  distance  of  4.3  cm.  The  large  cyst  was  filled  with  clear  yellow  fluid, 
which  contained  albumin  and  mucin.  Microscopic  examination  showed  poly- 
morphous epithelium,  pus-cells,  and  red  blood-corpuscles.  In  the  smaller  cyst 
the  epithelium  was  normal  and  there  was  no  evidence  of  pus-cells. 

Wutz  (p.  404)  sums  up  the  results  of  his  observations  of  the  urachus  and  urachal 
cysts  as  follows: 

1.  All  the  observed  cysts  have  been  located  in  the  lower  fourth  or  lower  third 
of  the  distance  from  the  urachus  to  the  top  of  the  bladder,  and  originated  from  the 
normally  persistent  portion  of  the  urachus. 

2.  In  the  majority  of  the  cases  they  were  lined  with  several  layers  of  flat  epi- 
thelium. 

3.  The  cysts  had  a  more  or  less  strongly  developed  covering  of  smooth  muscle- 
fibers. 

4.  The  size  of  the  cysts  varied  from  that  of  microscopic  objects  to  that  of  a  large 
bean. 

5.  Laminated  bodies  contained  in  the  cyst  fluid  did  not  stain  blue  with  iodin, 
but  yellow,  and  they  did  not  consist  of  amyloid  substance. 

6.  Concretions  in  the  canal  of  the  urachus  or  in  the  urachal  cysts  were  of  rare 
occurrence,  and  then  reached  only  a  small  size. 

7.  Urachal  cysts  were  sometimes  the  seat  of  inflammatory  changes. 

Morestin,  in  1900,  reported  a  case  in  which  two  small  urachal  cysts  were  dis- 
covered between  the  muscle  and  peritoneum  during  an  abdominal  operation  for  a 
left  pus-tube.  They  were  too  small  to  be  recognized  before  operation.  They  were 
arranged  one  above  the  other,  but  were  independent.  The  cord  of  the  urachus 
passed  from  the  summit  of  the  bladder  and  disappeared  in  the  lower  cyst.  It 
was  again  recognized  above  the  upper  cyst,  and  could  be  followed  to  the  umbilicus. 
The  peritoneum  was  loosely  attached  to  the  cysts.  The  cysts  were  globular, 
smooth,  transparent,  of  a  bluish  tinge,  and  contained  a  limpid,  colorless  fluid. 
Their  inner  surfaces  were  smooth  and  presented  a  serous  aspect.  There  was  an 
outer  covering  of  connective  tissue  and  an  inner  lining  of  flattened  epithelium. 
These  cysts  manifestly  had  originated  from  the  urachus. 

Wyss,  in  1870,  under  the  title  of  "A  Cyst  Near  the  Umbilicus,"  reported  his 
findings  at  autopsy.  Between  the  peritoneum  and  muscle,  a  little  to  the  side  of 
the  linea  alba,  and  about  one  inch  above  the  umbilicus,  was  a  cyst  the  size  of  a  bean. 
It  contained  turbid,  tenacious  mucus,  grayish  yellow  in  color.  It  was  lined  with 
cylindric  epithelium.  Wyss  thought  that  the  cyst  had  resulted  from  embryonic 
remains. 

The  location  of  the  cyst,  the  changes  in  the  epithelium,  and  the  cyst  contents 
strongly  suggest  that  it  had  originated  from  remnants  of  the  omphalomesenteric 
duct. 


528  THE    UMBILICUS    AND    ITS    DISEASES. 

Opitz.  in  his  article  on  Urachal  Cysts  published  in  1905,  referred  to  a  cyst  of 
the  abdominal  wall  and  said  that  it  looked  like  an  appendix;  that  it  was  lined  with 
one  layer  of  low  epithelium,  and  was  surrounded  by  a  circular  layer  of  muscle, 
outside  of  which  was  a  longitudinal  muscular  layer.  From  the  description  it  is 
impossible  to  get  a  clear  idea  of  the  case. 

Caruso,  when  operating  on  a  woman  forty-two  years  old  for  removal  of  a  myoma, 
noted  a  small  cyst  at  the  level  of  the  umbilicus.  This  was  lined  with  cuboid  epi- 
thelium. He  also  noted  tubular  glands  and  non-striped  muscle.  The  location  of 
this  cyst  would  throw  some  doubt  upon  its  urachal  origin,  and  the  presence  of 
tubular  glands  suggests  that  it  may  have  originated  from  remains  of  the  omphalo- 
mesenteric duct  or  from  uterine  glands  at  the  umbilicus. 

Weiser,  in  his  article,  says  that  he  received  personal  letters  from  Wm.  J.  Mayo, 
Nicholas  Senn,  Edwin  Martin,  W.  A.  Smith,  Roswell  Park,  J.  F.  Erdmann,  Howard 
A.  Kelly,  DeForest  Willard,  and  from  E.  Wyllys  Andrews,  saying  that  they  had 
personally  encountered  instances  of  cysts  of  the  urachus. 

From  the  foregoing  it  is  seen  that  small  urachal  cysts  are  found  between  the 
bladder  and  umbilicus,  and  that  they  lie  between  the  muscles  and  peritoneum  of  the 
anterior  abdominal  wall.  There  ma3r  be  only  one  cyst  or  several  in  a  row.  They 
may  be  minute  or  reach  a  centimeter  or  more  in  diameter.  They  have  thin  walls, 
and  may  be  transparent  or  translucent.  Their  inner  surfaces  are  smooth.  They 
are  lined  with  transitional  or  cylindric  epithelium.  The  cyst  fluid  contains  al- 
bumin, mucin,  and  exfoliated  epithelium,  and  sometimes  polymorphonuclear 
leukocytes  and  red  blood-cells.     They  are  merely  dilatations. 

Wutz's  observations  on  small  urachal  cysts  are  the  most  complete  that  we 
possess.     It  will  be  of  interest  to  glance  through  the  22  cases  that  he  has  recorded. 

Case  1  .  —  A  nineteen-j^ear-old  boy  had  had  a  right-sided  otitis  media. 
The  urachus  was  the  seat  of  several  small  cystic  dilatations,  some  of  which  communi- 
cated with  one  another. 

Case  2  .  —  A  girl,  twenty  years  of  age,  died  of  tuberculous  peritonitis.  The 
distance  of  the  umbilicus  from  the  vertex  of  the  bladder  was  20  cm.  The  length  of 
the  epithelial  tube  was  3.6  cm.  The  latter  terminated  in  five  transparent  cysts 
the  size  of  pin-heads. 

Case  3""  —  A  twenty-three-year-old  man  died  of  pulmonary  tuberculosis. 
The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  17  cm.,  and  the 
length  of  the  epithelial  tube,  4  cm. 

The  latter  ran  straight,  could  be  sounded,  and  terminated  in  three  cysts  the 
size  of  millet-seeds. 

Case  4  .  —  A  woman,  twenty-four  years  of  age,  died  of  pulmonary  tubercu- 
losis. The  distance  from  the  umbilicus  to  the  top  of  the  bladder  was  26.5  cm.  At 
a  point  3.7  cm.  from  the  bladder,  lying  on  the  left  side  and  communicating  with  the 
canal,'  was  a  cyst  the  size  of  a  pea. 

fas  e  5  .  —  The  woman,  twenty-seven  years  of  age,  was  suffering  with  "sar- 
comatous struma."  The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder 
was  20.8  fin.  About  0.5  cm.  above  the  vertex,  on  the  side,  was  a  transparent 
cyst  the  size  of  a  millet-seed. 

Case  6  .  —  The  patient  was  a  woman,  thirty-one  years  of  age,  with  pulmonary 
tuberculosis.  The  distance  from  the  vesical  vertex  to  the  umbilicus  was  17  cm. 
The  epithelial  tube  could  he  sounded,  the  probe  passing  directly  upward.     In  the 


SMALL    URACHAL    CYSTS.  529 

middle  of  its  course  the  tube  was  obstructed,  but  the  canal  again  appeared  and 
terminated  in  a  small  cyst,  conic  in  form,  and  almost  1  mm.  long. 

Case  7  .  —  The  patient  was  a  man,  thirty-six  years  of  age,  who  had  pul- 
monary tuberculosis.  The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder1 
was  15.5  cm.  The  length  of  the  epithelial  tube  was  4.4  cm.  At  a  point  0.75  mm. 
from  the  top  of  the  bladder  was  a  spindle-like  dilatation,  0.71  mm.  long  and  0.1  mm. 
broad. 

Case  8  .  —  A  man,  thirty-eight  years  of  age,  died  of  tuberculosis.  The 
distance  from  the  umbilicus  to  the  vertex  was  25  cm.  The  length  of  the  epithelial 
tube  was  0.7  cm.  At  a  point  3  mm.  from  the  vertex  of  the  bladder  was  a  spindle- 
like dilatation  varying  from  1.5  to  0.42  mm.  in  diameter.  About  1  mm.  from  this 
was  a  second,  2  mm.  long,  0.67  mm.  broad. 

Case  9  .  —  The  subject  was  a  woman,  thirty-nine  years  of  age,  dead  of  cere- 
bral hemorrhage.  The  distance  from  the  umbilicus  to  the  vertex  was  20.5  cm. 
The  length  of  the  epithelial  tube  was  4.3  cm.  At  a  point  2.5  cm.  above  the  vertex 
of  the  bladder  was  a  dilatation  3.5  x  1.5  mm.,  filled  with  a  yellowish,  crumbly 
material. 

Case  10.  —  The  subject  was  a  woman  forty  years  of  age,  dead  of  tuber- 
culous cerebrospinal  meningitis.  The  distance  from  the  umbilicus  to  the  vertex  of 
the  bladder  was  18.8  cm.,  and  the  length  of  the  epithelial  tube  was  1.9  cm.  About 
1  cm.  above  the  vertex  of  the  bladder  were  two  cysts  attached  to  the  left  side 
of  the  tube.  The  first  was  roundish  and  measured  0.54  x  0.3  mm.  The  second  was 
0.63  x  0.49  mm.  Scattered  throughout  the  entire  length  of  the  tube  were  numerous 
small  dilatations.  These  were  somewhat  pedunculated,  and  were  situated  on  all 
sides  of  the  tube. 

Case  11.  —  The  man,  forty-three  years  of  age,  had  died  of  delirium  tremens. 
The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  20  cm.  The 
length  of  the  epithelial  tube  was  5.6  cm.  In  the  bladder  mucosa  there  was  a  dis- 
tinct groove.  At  a  point  3.5  cm.  above  the  bladder  were  three  nipped-off  cysts 
the  size  of  millet-seeds.  A  short  distance  from  the  bladder  the  tube  contained  an 
oval  body,  0.17  x  0.1  mm.  This  was  brownish  in  color  and  homogeneous  in  con- 
sistence. In  the  further  course  of  the  tube  were  several  diverticula  and  nipped-off 
cysts  of  various  forms,  filled  with  firm  brown  contents. 

Case  12.  —  The  man,  forty-three  years  of  age,  had  died  of  pachymeningitis. 
The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  12  cm.  Pro- 
jecting from  the  top  of  the  bladder  were  two  small  cystic  dilatations. 

Case  13.  —  A  woman,  forty-three  years  old,  had  died  from  degeneration  of 
the  heart.  The  distance  from  the  umbilicus  to  the  base  of  the  bladder  was  15  cm. 
The  epithelial  tube  was  5.4  cm.  long.  The  tube  showed  four  spindle-shaped  cysts; 
the  largest  was  1.5  cm.  above  the  vertex  of  the  bladder  and  measured  6x2  mm. 

Case  14.  —  The  man,  forty-five  years  of  age,  had  died  of  pulmonary  tu- 
berculosis. The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  16  cm. 
The  length  of  the  epithelial  tube  was  5  cm.  At  a  point  3  mm.  above  the  top  of  the 
bladder  was  a  cyst  the  size  of  a  millet-seed,  with  a  second  the  size  of  a  pin-head  on 
the  top  of  it.  The  tube  passed  for  a  distance  of  3  cm.  and  terminated  with  three 
cysts  resembling  a  string  of  pearls.  Besides  these  were  numerous  round,  oval 
cysts,  recognized  microscopically. 

Case    15.  —  The  man,  sixty-five  years  of  age,  had  died  of  typhoid  fever. 
35 


530  THE    UMBILICUS    AND    ITS    DISEASES. 

The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  26  cm.  The 
length  of  the  epithelial  tube  was  5.5  cm.  From  the  top  of  the  bladder  the  tube 
passed  directly  upward  and  formed  at  the  junction  of  the  lower  middle  third  a 
beautifully  spindle-shaped  cyst,  not  nipped  off.  This  was  1.6  mm.  long  and  0.4  mm. 
broad.  Above  this  point  the  tube  showed  numerous  diverticula  extending  as  far 
up  as  3  cm.  Here  there  was  a  broad-based  cyst  projecting  from  the  right  side.  It 
was  oval  and  measured  2.16  x  1.62  mm.  These  cysts  were  filled  with  lumps  of 
brownish  yellow  material. 

Case  16.  —  The  man,  sixty-one  years  of  age,  had  died  of  pachymeningitis 
with  hemorrhage.  The  distance  from  the  umbilicus  to  the  vertex  was  19  cm.  The 
length  of  the  epithelial  tube  was  3.1  cm.  It  showed  diverticula  and  cysts.  They 
were  arranged  in  groups  around  the  canal,  and  at  first  sight  suggested  acinous 
glands. 

Case  17.  —  The  woman,  sixty-six  years  old,  had  died  of  an  incarcerated 
hernia.  The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  22.5  cm. 
The  length  of  the  epithelial  tube  was  7.7  cm.  Commencing  1  mm.  above  the  top 
of  the  bladder  were  five  pearl-like  cysts,  almost  round  and  transparent.  The 
first,  third,  and  fifth  were  the  size  of  small  peas,  while  the  two  between  them  were  as 
large  as  millet-seeds.  The  dilatations  opened  into  one  another,  and  the  tube  for 
several  centimeters  further  admitted  a  fine  bristle  (Fig.  226,  p.  520).  The  con- 
tents were  yellowish-white  and  friable.  Commencing  4.8  cm.  above  the  bladder 
were  six  cysts  of  the  size  of  pin-heads  containing  transparent  fluid. 

Case  18.  —  The  man,  sixty-seven  years  of  age,  had  died  of  bronchopneu- 
monia. The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  16  cm. 
The  epithelial  tube  was  4.8  cm.  long.  Situated  4.6  cm.  above  the  bladder  was  a 
spindle-shaped  cyst,  2x1  mm.,  with  brownish-yellow  contents. 

Case  19.  —  The  man,  sixty-nine  years  of  age,  had  died  of  cardiac  degenera- 
tion. The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  22.5  cm. 
The  epithelial  tube  at  the  bladder  had  a  diameter  of  0.3  mm.  Beyond  this  point 
were  three  cysts,  the  largest  10  mm.  in  diameter.  The  cysts  communicated  with 
one  another. 

Case  20.  —  The  subject  was  a  man,  sixty-five  years  old,  who  had  had 
softening  of  the  brain  due  to  an  embolus.  The  distance  from  the  umbilicus  to  the 
vertex  of  the  bladder  was  21.5  cm.  The  epithelial  tube  was  6  cm.  long.  The 
mucosa  of  the  bladder  at  the  vertex  showed  a  definite,  tent-like  depression.  Then 
there  was  a  canal  1.6  cm.  long  and  irregularly  dilated.  Situated  3  mm.  above  this 
was  a  spindle-shaped  dilatation,  2  cm.  x  4.5  mm. 

Case  21.  —  The  man,  seventy-three  years  old,  had  died  of  carcinoma  of  the 
esophagus.  The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  19.5 
cm.  The  epithelial  tube  was  0.6  cm.  long.  Situated  2  mm.  from  the  vertex  were 
two  pin-head-sized,  transparent  cysts. 

Case  22.  —  The  man,  seventy-three  years  old,  had  died  of  bronchopneu- 
monia. The  distance  from  the  umbilicus  to  the  vertex  of  the  bladder  was  16  cm. 
The  epithelial  tube  was  6.7  cm.  long.  About  1  cm.  from  the  top  of  the  bladder  was 
a  spindle-shaped  cyst,  0.7  cm.  long  and  0.3  cm.  broad.  Situated  0.3  cm.  above 
this  was  a  second  cyst,  nearly  2  cm.  in  length  and  4.5  mm.  broad  (Fig.  227,  p.  520). 

Wutz  in  discussing  these  cysts  says  that  the  epithelium  taken  from  the  inner 
surface  of  the  fresh  cysts  consisted  of  cells  of  various  forms  and  sizes.     A  transverse 


SMALL    URACHAL    CYSTS.  531 

section  through  the  cysts  showed  that  they  had  an  epithelial  lining,  then  a  structure- 
less membrane,  then  a  delicate  connective  tissue,  and  numerous  smooth  muscle- 
fibers  were  arranged  chiefly  longitudinally.  In  the  walls  were  a  small  number 
of  blood-vessels.  The  acinous  glands  described  by  Luschka  were  not  observed  by 
Wutz.  He  saw,  however,  quite  frequently  the  lateral  dilatations  that  gave  a 
picture  of  a  grape-like  formation.  The  cysts  contained  partly  transparent,  partly 
yellowish  or  yellowish-brown  or  brownish-red  masses.  In  the  first  case  the  con- 
tents were  fluid,  in  several  of  the  later  ones  they  were  firm.  There  were  numerous 
fat-crystals,  fat-droplets,  and  free  fat,  large  fat-cells,  brownish-yellow  amorphous 
masses,  isolated  cholesterin  crystals,  and  small,  round,  strongly  glistening  bodies. 


LITERATURE  CONSULTED  ON  SMALL  URACHAL  CYSTS. 
Caruso,  F. :    Contributo  alio  studio  anatomo-patologico  dei  tumori  cistici  dell'  ombelico.     Atti 

della  Soc.  Italiana  di  Ost.  e  Gin.,  1901,  viii,  293. 
Luschka,  H.:    Leber  den  Bau  des  menschlichen  Harnstranges.     Arch.  f.  pathologische  Anat. 

und  Physiol,  u.  f.  klin.  Medicin,  1862,  xxiii,  1. 
Morestin,  H.:   Kystes  de  l'ouraque.     Bull,  de  la  Soc.  anat.  de  Paris,  1900,  lxxv,  1040. 
Opitz:  Verhandl.  Deutsche  Gesellsch.  f.  Gyn.,  Kiel,  1905,  xi,  545. 
Veiel,  E.:   Die  Metamorphose  des  Urachus.     Diss.,  Tubingen,  1862. 
Weiser,  W.  R.:  Cysts  of  the  Urachus.     Annals  of  Surg.,  1906,  xliv,  529. 
Wutz,  J.  B.:  LTeber  Urachus  und  Urachuscysten.     Virchows  Arch.,  1883,  xcii,  387. 
Wyss,  H.:  Zur  Kenntnis  der  heterologen  Flimmercysten.     Virchows  Arch.,  1870,  li,  143. 

Personal  Observations  on  Small  Cysts  of  the  Urachus. 

As  far  back  as  1895  Dr.  Kelly  was  much  interested  in  small  urachal  remains 
that  from  time  to  time  were  noted  during  abdominal  operations;  and  for  a  year  or 
two  he  removed  portions  of  the  urachus  where  any  thickening  was  noted.  All 
these  I  examined  histologically.  Sometimes  the  cord  itself  would  show  a  uniform 
thickening,  as  in  Case  6902  (Path.  No.  3144).  Here  it  varied  from  3  to  8  mm.  in 
diameter,  and  yet  on  histologic  examination  there  was  no  evidence  of  a  lumen. 
The  center  was  composed  of  longitudinal  bundles  of  non-striated  muscle.  Sur- 
rounding this  was  fibrous  tissue,  and  external  to  the  latter  was  a  circular  muscular 
layer.  This  case  shows  that  a  large  urachal  cord  does  not  necessarily  mean  that 
the  urachus  is  patent. 

A  survey  of  the  accompanying  cases  will  show  that  the  cysts  varied  from  some 
very  minute  ones  to  others  measuring  1  x  0.9  cm.  From  our  experience  it  seems 
that  where  the  urachus  appears  as  a  single  dilated  tube,  the  duct  is  usually  lined 
with  several  layers  of  transitional  epithelium,  as  in  Fig.  229  (Gyn.  No.  6792)  and 
Fig.  232  (Path.  No.  17025).  It  may,  however,  have  only  a  single  layer  of  cylin- 
dric  epithelium,  as  seen  in  Fig.  228  (Gyn.  No.  3802). 

Occasionally  the  remnants  of  the  urachus  appear  as  a  small  multilocular  cyst, 
as  noted  in  Fig.  230  (Gyn.  No.  8250).  The  loculi  are  lined  with  cuboid  epithelium. 
It  is  probable  that  such  small  multilocular  cysts  represent  remnants  of  the  acini 
described  by  various  authors  as  projecting  from  the  sides  of  the  urachus. 

The  urachal  remains  were  in  every  case  surrounded  by  non-striped  muscle. 

Our  experience  leads  us  to  believe  that  remnants  of  the  urachus  in  the  adult  are 
by  no  means  rare. 

The  small  cysts  may  be  filled  with  colorless  fluid.     Frequently  they  contain 


532 


THE    UMBILICUS    AND    ITS    DISEASES. 


granular  debris  which  has  a  yellowish-brown  tinge,  and  swollen  and  granular  ex- 
foliated cells  containing  brown  pigment. 

Small  Cyst  of  the  U  r  a  c  h  u  s  .  —  Gyn.  No.  3802.  A.  P.,  aged 
twenty-five.  Admitted  November  19,  1895.  At  operation  the  uterus  was  sus- 
pended, the  perineum  repaired,  an  adherent  ovary  freed,  and  a  cyst  of  the  urachus 
removed  (Fig.  228). 

Path.  No.  887.  The  specimen  consists  of  fat  containing  a  small  cord  3  mm.  in 
diameter,  1  cm.  long.  This  ends  at  the  upper  end  in  an  oval  cyst,  1  x  0.9  cm., 
which  has  thin  walls  and  contains  clear  fluid.  This  cyst  is  lined  with  one  layer  of 
cuboid  cells,  showing  oval,  uniformly  staining  nuclei  parallel  with  the  cyst-wall. 
In  many  places  the  epithelium  appears  to  be  two  or  three  layers  in  thickness  where 


Fig.  228. — A  Small  Cyst  of  the  Urachus. 
Gyn.  No.  3802.     Path.  No.  887.     This  cyst  measured  1  x  0.9  cm.,  had  thin  walls,  and  contained  clear  fluid.     In 
the  handling,  the  cyst  has  been  somewhat  flattened.    It  is  embedded  in  adipose  tissue,  and  at  either  end  is  seen  a  fibrous 
COrd — the  obliterated  urachus.     The  definite  cyst-wall  is  composed  of  fibrous  tissue  and  non-striped  muscle.     The  cyst 
was  lined  with  one  layer  of  cuboid  cells. 


cut  on  the  bias.  It  is  surrounded  by  fibrous  tissue,  and  a  moderate  amount  of 
muscle  separates  it  from  the  surrounding  adipose  tissue. 

Diagnosis:  Small  cyst  of  the  urachus. 

Cyst  of  Urachus.  —  Gyn.  No.  6722.  E.  G.,  aged  forty-six.  Ad- 
mitted to  the  Johns  Hopkins  Hospital  February  27,  1899,  with  a  diagnosis  of 
uterine  myoma.  Operation:  Hysteromyomectomy,  excision  of  a  small  urachal 
cyst  found  lying  between  the  obliterated  hypogastric  arteries. 

Path.  No.  2947.  The  cyst  is  8  mm.  in  diameter.  Its  walls  average  1  mm.  in 
thickness.  On  histologic  examination  the  little  growth  is  found  to  consist  of  clusters 
of  alveoli  embedded  in  connective-tissue  stroma,  the  entire  area  being  surrounded 
by  fat  and  fibrous  tissue.  The  alveoli  vary  from  a  pin-point  to  1  mm.  in  diameter. 
Some  of  them  undoubtedly  communicated  with  one  another.  They  are  lined  with 
cuboid  epithelium  which  is  one  layer  in  thickness. 

Diagnosis:   Cyst  of  the  urachus. 


SMALL    URACHAL    CYSTS.  533 

A  Partially  Patent  Urachus.  —  Gyn.  No.  6739.  C,  aged  forty- 
nine.  Admitted  to  Ward  B,  Johns  Hopkins  Hospital,  March  6,  1899.  Operation: 
Dilatation  of  the  cervix  and  suspension  of  the  uterus.  A  portion  of  the  urachus  was 
excised. 

Path.  No.  2961.  The  piece  removed  was  1.8  cm.  long  and  varied  from  2  to  3 
mm.  in  thickness.  On  histologic  examination  the  lumen  of  the  urachus  was  found 
to  be  1  mm.  in  diameter.  It  was  lined  with  transitional  epithelium  two  or  three 
layers  in  thickness.  The  nuclei  of  the  epithelial  cells  were  round  or  oval,  and 
stained  uniformly.  External  to  the  epithelial  lining  was  a  varying  amount  of 
muscular  and  connective  tissue,  and  surrounding  the  whole  was  adipose  tissue. 

A  Partially  Patulous  Urachus.  —  Gyn.  6778.  Mrs.  S.,  ad- 
mitted to  Ward  B,  Johns  Hopkins  Hospital,  March  2,  1899.  During  the  course  of 
the  abdominal  operation  a  portion  of  the  urachus  was  removed.  This  piece  was 
1  cm.  long  and  varied  from  2  to  4  mm.  in  thickness. 

Path.  No.  3023.  The  small  cord  at  first  suggests  a  tube.  It  is  tortuous,  shows 
little  projections  into  it;  it  is  lined  with  one  or  sometimes  two  or  three  layers  of 
epithelium  and  completely  surrounded  by  non-striped  muscle.  Situated  near  the 
lumen  is  a  small,  gland-like  space  lined  with  cylinclric  cells.  Scattered  throughout 
the  muscle  are  quantities  of  blood-vessels.  In  many  respects  it  resembles  the 
Fallopian  tube  more  than  it  does  a  urachus,  but  at  other  points  the  similarity  is 
not  so  marked. 

A  Partially  Patent  U  r  a  c  h  u  s  .  —  Gyn.  No.  6792.  G.,  Ward  B. 
Operation:  Hysteromyomectomy,  drainage  of  gall-bladder,  excision  of  a  portion 
of  the  urachus. 

Path.  No.  3049.  The  portion  of  the  urachus  removed  is  in  two  pieces.  The 
first  (a)  is  2.5  cm.  long,  0.5  cm.  in  diameter,  and  removed  from  a  point  about  7  cm. 
above  the  summit  of  the  bladder,  b,  the  intervening  part,  is  7  cm.  long  and  1  mm. 
in  diameter.  In  the  first  specimen  there  is  a  definite  lumen  0.5  mm.  in  diameter, 
lined  with  two  or  three  layers  of  cells  of  the  transitional  type  (Fig.  229) .  The  nu- 
clei are  oval  or  round  and  stain  uniformly.  Surrounding  the  lumen  is  fibrous 
tissue,  a  small  number  of  non-stripecl  muscle-fibers,  and  external  to  this  adipose 
tissue.  There  is  no  doubt  that  we  have  here  remains  of  the  lumen  of  the 
urachus.  In  the  portion  near  the  bladder  the  lumen  has  been  completely  obliter- 
ated. 

Urachal  Remains.  —  Gyn.  No.  6902.  M.,  nineteen  years  old.  Ad- 
mitted to  Ward  B,  Johns  Hopkins  Hospital,  May  8,  1899.  The  operation  consisted 
of  hysterotomy,  curettage,  and  resection  of  an  ovary,  together  with  excision  of  a 
portion  of  the  urachus.  The  part  of  the  urachus  removed  was  3.5  cm.  long  and 
from  3  to  8  mm.  in  diameter.  These  measurements  included  some  of  the  surround- 
ing adipose  tissue. 

Path.  No.  3144.  Microscopically,  no  trace  of  the  lumen  could  be  made  out. 
In  the  center  was  a  stroma  consisting  of  bundles  of  non-striped  muscle  arranged 
longitudinally  and  surrounded  by  fibrous  tissue;  external  to  this  again  was  a 
circular  layer  of  muscle.  In  other  words,  this  cord  was  made  up  entirely  of  muscular 
and  fibrous  tissue  without  any  sign  of  a  lumen. 

A  Very  Small  Multilocular  Urachal  Cyst.  —  Gyn.  No. 
8250.  J.  W.,  married,  aged  twenty-seven.  Admitted  October  24,  1900.  The 
uterus  was  suspended  for  a  retroflexion,  and  a  cyst,  supposedly  of  the  urachus,  was 


534 


THE    UMBILICUS    AND    ITS    DISEASES. 


removed.     The  cyst  of  the  urachus  was  3x5  mm.     It  was  translucent  and  showed 
irregular,  tiny,  projections  into  the  cavity,  Fig.  230. 

Path.  No.  4441.  The  specimen  was  found  to  be  a  multilocular  cyst,  the  loculi 
being  large  and  small  and  apparently  opening  into  one  another.  The  epithelium 
in  some  places  was  cuboid.  The  nuclei  of  the  epithelial  cells  were  oval;  they 
stained  uniformly  and  were  arranged  parallel  with  the  cyst-wall.  Where  the  tissue 
was  cut  on  the  bevel,  the  epithelium  appeared  to  be  several  layers  in  thickness 
and  suggested  squamous  epithelium.  The  stroma  between  the  cysts  consisted 
essentially  of  non-striped  muscle-fibers  separating  the  cyst  proper  from  the  sur- 


*3k   ■ 


W-o'Wk 


Fig.  229. — A  Patent  Urachus. 
Gyn.  No.  6792.     Path.  No.  3049.     This  portion  of  the  urachus  was  in  the  mid-line,  about  7  cm.  above  the  blad- 
der.    The  lumen  is  slightly  irregular  and  contains  some  granular  detritus.     Lining  the  cavity  is  transitional  epithe- 
lium, in  some  places  only  as  a  single  layer,  but  at  most  points  two  or  three  layers  thick.     Surrounding  the  lumen  is 
fibrous  tissue  in  which  some  non-striped  muscle  was  recognized. 


rounding  fibrous  and  adipose  tissue.  This  cyst  was  a  remnant  of  the  urachus. 
Whether  the  loculi  all  communicated  with  one  channel  or  not  it  is  difficult  to  say. 

A  Partially  Patent  Urachus.  —  Path.  No.  3012.  This  patient 
was  admitted  to  Dr.  Kelly's  sanitarium  March  7,  1899.  The  operation  consisted 
of  an  abdominal  myomectomy  and  excision  of  the  urachus. 

Histologic  Examination. — The  lumen  is  found  narrow  and  lined  with  two  or 
three  layers  of  columnar  epithelium.  External  to  the  epithelium  are  bundles  of 
longitudinal  and  circular  muscle-fibers.     The  urachus  is  pervious. 

Probable  Cyst  of  the  Urachus.  —  Gyn.  No.  6815.  Path.  No. 
3062.  B.,  twenty-five  years  old.  Admitted  to  Ward  B,  Johns  Hopkins  Hospital, 
April  8,  1899. 


SMALL    URACHAL    CYSTS. 


535 


V:< 


i  ft* 


'  , 


X/5T7. 


-4fj/jk,,,6 


Fig.  230. — A  Multilocular  Cyst  of  the  Urachus. 
Gyn.  No.  8250.  Path.  No.  4441.  This  cyst  was  3x5  mm.  and  was  translucent.  As  seen  from  the  upper,  low- 
power  picture,  it  was  composed  of  numerous  loculi.  Many  of  these  seemed  to  communicate  with  one  another.  Sur- 
rounding the  cyst,  and  separating  it  from  the  adipose  tissue,  is  a  definite  wall.  This  consisted  of  fibrous  tissue  and  non- 
striped  muscle.  The  small  area  of  the  cyst-wall,  blocked  off  and  indicated  by  the  arrow,  has  been  enlarged  and  is 
seen  in  the  lower  picture.     The  cyst  is  lined  with  one  layer  of  cuboid  cells. 


536 


THE    UMBILICUS    AND    ITS    DISEASES. 


Operation. — Exploratory  laparotomy;  excision  of  a  small  cyst  from  the  ante- 
rior abdominal  wall  just  above  the  symphysis.  This  cyst  contained  two  small 
lumina,  which  appeared  to  be  convolutions  of  the  same  tube.  Each  was  lined 
with  two  or  more  layers  of  transitional  epithelium.  The  nuclei  of  the  epithelial 
cells  were  oval  and  stained  uniformly,  and  the  lumen  was  surrounded  b}r  non- 
striped  muscle-fibers  arranged  circularly.  External  to  these  were  parallel  bundles 
of  non-striped  muscle-fibers  embedded  in  fibrous  tissue.  It  seems  practically 
certain  that  they  were  remains  of  the  urachus. 

A    Partially    Patent    Urachus.  —  Gyn.  Path.  No.   17025.     While 


.'. ''  * 


LD  jggji  r> 


=% 


5i- 


Fig.  231. — Section  of  a  Patent  Urachus. 
Gyn.  Path.  No.  17025.     A  longitudinal  section  of  a  portion  of  the  urachal  cord.     The  tube  has  evidently  been 
tortuous,  thus  accounting  for  the  longitudinal  and  transverse  sections  of  the  lumen.     (For  the  high-power  picture  see 
Fig.  232.) 


collecting  the  literature  on  the  urachus  I  found,  when  operating  on  Mrs.  M.  E. 
at  the  Church  Home  and  Infirmary,  February  28,  1912,  a  urachal  cord  that  seemed 
unusually  large.  Longitudinal  sections  of  this  showed  elongate,  irregular,  and 
round  cavities  embedded  in  non-striped  muscle  and  fat.  The  low-power  picture 
is  well  shown  in  Fig.  231.  One  gathers  the  impression  that  the  urachus  consists 
of  one  tortuous  and  probably  slightly  branching  tube.  It  will  be  noted  that  these 
spaces  have  a  distinct  lining  and  that  some  of  them  are  filled  with  a  definite  sub- 
stance. From  Fig.  232  we  learn  that  the  spaces  are  lined  with  transitional  epi- 
thelium.    The  contents  of  the  cavities  were  in  the  main  brownish  yellow.     The 


SMALL    URACHAL    CYSTS. 


537 


small  oval  or  spheric  masses  are  swollen,  exfoliated  cells,  which  have  taken  up  pig- 
ment granules.     This  was  without  a  doubt  a  patent  and  slightly  cystic  urachus. 

A  Small  Urachal  Cyst.  —  Gyn.  No.  21255.  N.  D.,  aged  twenty- 
three,  white,  was  admitted  to  the  Johns  Hopkins  Hospital  on  June  4,  1915,  com- 
plaining of  severe  abdominal  pain  and  of  backache.  She  was  married  and  had  had 
one  child. 


Gyn.  Path.  No.  1702.5. 


Fig.  232. — Transverse  Section  of  a  Patent  Urachus. 
The  cavity  is  lined  with  several  layers  of  transitional  epithelium, 
amount  of  debris.     Surrounding  the  urachus  is  non-striped  muscle. 


It   contains  a   certain 


After  a  careful  examination  it  was  found  that  she  had  a  relaxed  vaginal  outlet 
and  a  retroposed  uterus,  chronic  appendicitis,  and  gall-stones. 

At  operation  Dr.  J.  Craig  Neel,  the  resident  gynecologist,  repaired  the  perineum, 
brought  up  the  uterus,  removed  the  appendix,  and  emptied  the  gall-bladder  of  its 
stones.  While  making  the  median  abdominal  incision  to  bring  up  the  uterus,  he 
found  a  small  cyst  of  the  urachus  in  the  mid-line  (Fig.  233).     This  cyst  was  about 


538 


THE    UMBILICUS    AND    ITS    DISEASES. 


1  x  1.5  cm.  in  diameter,  and  seemed  to  be  filled  with  clear  fluid.     The  cyst  and 
about  1  cm.  of  the  urachus  on  each  end  of  it  were  removed. 

Gyn.-Path.  No.  21256.     Sections  from  the  cyst  wall  show  that  it  is  composed 
in  a  large  measure  of  connective  tissue  with  here  and  there  a  little  non-striped 


Obliterated  urachus 

Josten'or  surface  of 
Urachus  cyst 

faterct  urachus 


Fig.  233. — A  Small  Cyst  of  the  Urachus. 
Gyn.  Path.  No.  212.56.  This  cyst  was  accidentally  discovered  when  a  median  abdominal  incision  was  being  made. 
The  cyst  was  located  at  a  point  midway  between  the  umbilicus  and  symphysis.  It  was  thin-walled,  and  above  and 
below  was  directly  continuous  with  the  urachal  cord.  In  the  urachus  just  below  the  cyst  were  three  slit-like  open- 
ings— points  at  which  the  urachus  was  apparently  still  patent.  The  small  drawing  in  the  right  upper  corner  of  the 
picture  shows  the  cyst  after  removal.     The  urachus  above  was  obliterated;   below,  it  was  patent  for  a  short  distance. 


muscle.     The  cyst  is  lined  with  one  layer  of  almost  flat  epithelium.     The  wall 
in  most  places  is  smooth  but  here  and  there  is  slightly  wavy. 

The  solid  cord  above  the  cyst  consists  almost  entirely  of  connective  tissue. 
The  urachal  cord  is  composed  in  part  of  connective  tissue,  but  contains  many 
bundles  of  non-striped  muscle.  The  slit-like  spaces  noted  macroscopically  are 
devoid  of  any  epithelium.     There  is  no  doubt  that  this  cyst  is  of  urachal  origin. 


CHAPTER  XXXII. 
LARGE  URACHAL  CYSTS. 

Historic  sketch. 

Symptoms. 

Differential  diagnosis;  personal  observations  on  a  large  diffuse  neuroma  of  the  bladder. 

Treatment. 

Detailed  report  of  large,  non-infected  urachal  cysts. 

The  small  urachal  cysts  that  we  have  considered  rarely  reached  1  cm.  in  diame- 
ter, and  were  naturally  readily  overlooked  clinically.  Probably  one  of  the  first 
urachal  cysts  ever  opened  was  the  one  observed  by  Peu  in  1648,  and  recorded  in  his 
Pratique  des  Accouchements,  1694,  p.  38,  and  recently  referred  to  by  Wutz.  The 
patient  was  a  child  two  hours  old.  Situated  at  the  umbilicus  was  a  tumor  the  size 
of  a  pigeon's  egg.  It  was  opened,  and  a  serum-like  fluid  escaped.  This  proved 
to  be  urine,  and  on  the  following  morning  urine  escaped  in  a  jet  from  the  umbilicus.. 

Atlee,  in  1873,  in  his  treatise  on  Ovarian  Tumors,  reported  the  case  of  a  girl 
eighteen  years  old.  When  opening  the  abdomen  for  the  removal  of  an  ovarian 
tumor  he  accidentally  incised  a  urachal  cyst  containing  an  ounce  of  fluid  resembling 
ordinary  ascitic  fluid. 

Von  Recklinghausen  in  1902  demonstrated  a  polycystic  tumor  the  size  of  a 
walnut  which  had  been  excised  from  a  man  thirty  years  old. 

E.  R.  LeCount  found  a  urachal  cyst  the  size  of  an  orange  while  making  an 
autopsy  on  a  man  fifty-two  years  of  age. 

Interesting  articles  on  urachal  cysts  have  been  written  by  Rippmann  (1872), 
Wolff  (1873),  Scholz  (1878),  Schaad  (1886),  Tait  (1886),  Dossekker  (1893),  Douglas 
(1897),  and  others,  and  in  1906  the  splendid  monograph  of  Weiser  appeared. 

These  cysts  are  naturally  first  noted  in  the  mid-line  between  the  umbilicus  and 
pubes.     They  lie  in  the  anterior  abdominal  wall  just  external  to  the  peritoneum. 

Size.  —  In  the  beginning  they  are  relatively  small,  as  in  von  Recklinghausen's, 
Atlee's,  and  LeCount's  cases.  As  a  rule,  the  increase  in  size  is  only  gradual,  but 
in  a  few  instances  the  growth  has  been  very  rapid.  They  rarely  extend  above  the 
umbilicus,  but  in  some  instances  have  reached  as  far  as  the  xiphoid.  Among  the 
largest  cysts  are  those  recorded  by  Pratt  and  Bond,  Macdonald,  Rippmann,  and 
Tait.  In  Pratt  and  Bond's  case  the  cyst  reached  upward  beneath  the  liver.  Mac- 
donald's  patient  had  a  markedly  distended  abdomen;  it  was  firm  and  rather  flat 
as  far  as  the  ensiform  cartilage.  In  Tait's  Case  1,  30  pints  of  fluid  were  evacuated 
at  operation.  Rippmann's  was  probably  the  largest  on  record.  At  autopsy  the 
cyst  was  found  to  contain  52  liters  of  fluid  weighing  100  pounds. 

The  cyst  may  or  may  not  burrow  beneath  the  bladder,  and  encroach  on  the 
vaginal  vault.  It  is  sometimes  attached  to  the  bladder  by  the  urachal  cord,  and 
where  the  tumor  has  reached  large  proportions,  it  is  usually  adherent  to  the  um- 
bilicus. 

The  cyst-walls  vary  considerably  in  thickness.  Some  are  verj^  thin,  others  may 
be  from  1  to  4  mm.  thick. 

539 


540  THE    UMBILICUS    AND    ITS    DISEASES. 

The  inner  surface  of  the  cyst  is  usually  smooth.  Sometimes  coagulated  cyst 
fluid  clings  to  its  walls.  In  Macdonald's  case  papillary  masses  were  found  springing 
from  the  inner  surface  of  the  cyst  (Fig.  240,  p.  559). 

As  these  cysts  are  due  to  dilatations  of  the  urachus,  we  should  naturally  expect 
to  find  them  lined  with  transitional  epithelium.  When  the  cysts  are  small,  the 
lining  with  transitional  epithelium  is  often  found,  but  in  the  large  cysts,  there  not 
being  enough  to  cover  the  whole  surface,  remnants  of  this  transitional  epithelium 
are  often  found  only  over  certain  areas  on  the  cyst-wall.  The  walls  are  composed 
of  fibrous  tissue  and  contain  a  varying  quantity  of  non-striped  muscle.  In  Tait's 
Case  XI  calcareous  particles  were  found  scattered  throughout  the  wall  of  the  cyst. 

Cyst  Fluid.  —  The  character  of  the  fluid  contained  in  urachal  cysts 
varies  considerably.  Sometimes  it  is  pale  yellow  and  limpid,  closely  resembling 
ascitic  fluid.  In  other  cysts  it  is  yellow  and  transparent  or  tenacious  and  ropy. 
The  fluid  may  be  of  a  pale-green  color.  In  some  cysts  it  is  brown  or  of  a  chocolate 
color;  or  it  may  be  thin  and  with  a  hemorrhagic  tint.  Whether  the  fluid  be  thin 
and  clear,  or  dark  and  turbid,  it  often  contains  large  clumps  of  coagulated  lymph 
or  fibrin.  Such  masses  have  been  referred  to  by  some  writers  as  "necrotic  lymph " 
or  cheesy  masses.  They  are  strongly  suggestive  of  the  coagulated  material  often 
noted  in  ovarian  cysts.  The  cyst  fluid  contains  albumin  and  mucus.  On  histologic 
examination  exfoliated  squamous  epithelium,  fat-droplets,  and  cholesterin  crystals 
are  often  noted. 

SYMPTOMS. 

Sex.  —  Of  the  cases  of  simple  uncomplicated  and  non-infected  urachal  cysts 
here  recorded,  and  in  which  we  were  able  to  obtain  definite  data  as  to  the  sex,  16 
were  in  women  and  5  in  men. 

Age.  —  The  youngest  patient  was  six  years  and  the  oldest  fifty-four.  The 
accompanying  table  furnishes  the  following  data: 

Six  years  of  age 1  case 

Between  ten  and  twenty  years 1      " 

"       twenty  and  thirty  years 1     " 

"      thirty  and  forty  years 7  cases 

"       forty  and  fifty  years 3      " 

"       fifty  and  sixty  years 2      " 

The  first  symptom  is  usually  enlargement  of  the  lower  part  of  the  abdomen. 
This,  as  a  rule,  is  in  the  mid-line,  but  the  swelling,  sometimes  accompanied  by  pain, 
may  first  be  noticed  in  the  right  iliac  fossa,  and  the  picture  may  strongly  suggest 
an  appendicitis. 

With  the  increase  in  abdominal  girth  there  may  be  a  moderate  degree  of  indi- 
gestion, and  where  the  cyst  has  reached  large  proportions,  there  has  been  dyspnea. 
Some  of  the  patients  have  become  progressively  emaciated  and  have  lost  in  strength. 

Micturition  has  been  normal  in  some,  frequent  in  others.  It  is  but  natural  that 
the  bladder  should  be  markedly  encroached  upon  in  some  cases,  particularly  as  the 
excursus  of  the  tumor  is  limited,  on  the  one  side  by  the  peritoneum,  and  on  the 
other  by  the  anterior  abdominal  wall. 

Pain  has  been  a  marked  feature  in  some  cases,  absent  in  others.  The  pain  is 
probably  in  a  measure  due  to  pressure  on  the  terminal  sensory  nerve-trunks,  owing 


LARGE    URACHAL    CYSTS.  541 

to  the  tension  under  which  the  cyst  develops,  confined,  as  it  is,  between  the  layers 
of  the  abdominal  wall.  But  it  must  also  be  remembered  that  the  cyst  is  separated 
from  the  abdominal  contents  only  by  a  thin  peritoneum,  and  consequently  the 
slightest  inflammation  of  the  cyst-wall  must  readily  extend  to  the  peritoneum  and 
not  only  produce  pain,  but  also  cause  the  omentum  or  some  other  abdominal 
structure  to  become  adherent  to  the  abdominal  wall  over  the  cyst.  Such  a  condi- 
tion was  noted  in  Carroll's  case,  and  also  in  one  recorded  by  Doran. 

On  physical  examination  an  abdominal  swelling  is  noted.  This  may  extend 
over  the  entire  abdomen,  or  be  limited  to  the  lower  portion.  Although  the  tumor 
may  be  exceedingly  large,  there  exists  a  certain  amount  of  repression  of  the  ab- 
dominal wall,  due  to  the  tonic  contraction  of  the  recti  muscles.  When  the  patient 
is  anesthetized  and  the  recti  muscles  are  relaxed,  instead  of  being  board-like,  the 
abdomen  may  become  quite  soft,  and  the  cystic  tumor  can  then  be  readily  detected. 
If  the  abdominal  walls  are  naturally  tense,  the  difficulties  in  making  an  accurate 
diagnosis  are  augmented.     In  some  cases  definite  fluctuation  can  be  elicited. 


DIFFERENTIAL  DIAGNOSIS. 

Urachal  cysts  have  been  diagnosed  as  a  distended  bladder,  as  ascites,  as  an 
appendicitis  with  abscess  formation,  as  a  cyst  with  or  -without  twisting  of  the 
pedicle,  as  a  localized  peritonitis  with  a  serous  exudate  under  the  anterior  ab- 
dominal wall,  and  as  a  tuberculous  peritonitis. 

The  distended  bladder  is  readily  emptied,  and  the  ascites  relieved  by  para- 
centesis. With  the  patient  asleep,  it  is  relatively  easy  to  outline  the  cyst  and 
to  differentiate  it  by  the  absence  of  the  induration,  usually  associated  with  an 
appendix  abscess.  Furthermore,  with  the  abscess  there  is  likely  to  be  a  history 
of  an  elevation  of  temperature  and  of  a  definite  leukocytosis. 

An  ovarian  cyst,  whether  mobile  or  twisted,  lies  much  farther  back  in  the  ab- 
domen and  can  be  separated  from  the  anterior  abdominal  wall,  particularly  when 
the  patient  is  under  narcosis.  The  differentiation  from  a  localized  peritonitis  or 
from  a  tuberculous  peritonitis  is  not  so  easy,  particularly  when  the  patient  has 
become  emaciated.  Even  in  these  cases,  however,  when  the  patient  is  asleep, 
the  sharp  outlines  of  the  urachal  cyst  are  readily  distinguishable  from  the  rather 
diffuse  cystic  accumulation  occurring  with  a  peritonitis.  Again,  in  the  case  of  a 
urachal  cyst,  moving  it  from  side  to  side  is  likely  to  produce  traction  on  the  umbili- 
cus. With  an  aspirating  needle  one  can  readily  remove  some  of  the  cyst  fluid  and 
thus  usually  settle  the  diagnosis. 

The  following  case  that  recently  came  under  my  notice  is  of  such  interest  in 
connection  with  the  differential  diagnosis  of  urachal  cysts  that  I  shall  report  its 
salient  features. 

A  Tremendously  Thickened  B 1  a  d  d  e  r - w  a  1 1  Producing 
a  Tumor  Reaching  Almost  to  the  Umbilicus  and  Simulat- 
ing a  Urachal  Cyst.  —  The  great  thickening  of  the  vesical  wall  was  due 
to  a  diffuse  neuroma.  I  shall  refer  to  this  case  very  briefly,  as  Dr.  Welch  and  I  will 
report  it  in  detail  elsewhere. 

Surg.  No.  34093.  P.  B.,  a  colored  boy  three  years  and  seven  months  old.  was 
admitted  to  the  surgical  service  of  the  Johns  Hopkins  Hospital  on  March  9,  1914. 
for  an  ununited  fracture  of  the  left  tibia  and  fibula.     Dr.  Heuer  wired  the  ununited 


542 


THE    UMBILICUS    AND    ITS    DISEASES. 


fracture,  and  the  boy  made  an  uneventful  recovery.  When  he  entered  the  hospital 
it  was  noted  that  he  had  a  firm  mass  extending  upward  from  the  symphysis  to 
within  2  cm.  of  the  umbilicus.     This  mass  was  broad  below  and  rather  narrow  near 


«  3  1 5 


Fig.  234. — A  Diffuse  Neuroma  of  the  Bladder.  (After  William  H.  Welch  and  Thomas  S.  Cullen.) 
The  picture  shows  the  appearance  of  the  bladder  when  the  abdomen  was  opened.  The  contracted  viscus  extended 
almost  to  the  umbilicus,  was  large  and  exceedingly  hard,  and  even  after  it  had  been  brought  out  of  the  abdomen,  it 
was  almost  impossible  to  realize  that  it  was  the  bladder.  When  the  bladder  was  lifted  up,  it  was  found  that  the  right 
ureter  was  8  mm.  in  diameter.  The  left  ureter  was  slightly  enlarged.  The  surface  of  the  bladder  was  covered  with 
great  congeries  of  what  appeared  to  be  small  and  tortuous  vessels.  These  were  noted  at  once,  but  were  particularly 
well  seen  when  the  peritoneum  was  stripped  back.  Subsequent  histologic  examination  showed  that  most  of  these  tor- 
tuous cords  were  nerves.  The  remnant  of  the  urachus  was  larger  than  usual.  Not  knowing  at  the  time  the  unusual 
character  of  the  growth,  I  cut  into  it  and  found  that  the  tumor  was  caused  by  a  tremendous  thickening  of  the  bladder- 
wall.     For  the  appearance  of  the  cut  bladder-wall  see  Fig.  235;   for  the  histologic  picture  see  Fig.  236. 


the  umbilicus.  Through  the  lax  abdominal  walls  it  could  be  readily  grasped  with 
the  hand.  Micturition  was  normal,  and  when  the  bladder  was  empty,  this  tumor 
diminished  little,  if  any,  in  size. 

It  seemed  to  be  a  urachal  tumor  of  some  kind,  and  Professor  Halsted,  knowing 


LARGE    URACHAL    CYSTS. 


543 


that  I  was  much  interested  in  urachal  remains,  kindly  transferred  the  case  to  the 
Gynecologic  Department. 

Operation  (March  28,  1914). — Feeling  confident  that  we  were  dealing  with  a 


Fig.  235. — Cut  Surface  of  the  Bladder  Showing  a  Diffuse  Neuroma  of  its  Walls. 
(After  William  H.  Welch  and  Thomas  S.  Cullen.) 
The  figure  shows  the  lower  part  of  the  bladder  seen  in  Fig.  234,  after  the  top  had  been  removed.  The  bladder- 
walls  protruded  into  the  cavity,  rendering  it  very  small.  The  inner  surface  at  this  point  was  covered  over  with  only.a 
single  layer  of  epithelium,  which  stained  very  faintly.  All  trace  of  the  transitional  epithelium  was  wanting  in  the 
sections  examined.  The  bladder-walls  in  the  portion  removed  varied  from  1  to  3  cm.  in  thickness,  and  everywhere 
this  coarse  and  tortuous  texture  was  the  striking  characteristic.  A  low-power  section  through  the  bladder-wall  showed 
an  abundance  of  nerves  on  the  outer  surface.  There  was  a  muscular  zone  with  nerve-bundles  scattered  throughout  it, 
and  an  inner  zone,  varying  from  1  to  2  cm.  broad,  consisting  almost  entirely  of  nerve  elements.     (See  Fig.  236.) 


urachal  tumor,  I  made  a  median  incision  from  the  umbilicus  to  the  symphysis,  and 
at  once  encountered  the  tumor  seen  in  Fig.  234.  It  was  very  firm,  and  over  a  large 
area  was  covered  with  peritoneum.  Attached  to  its  upper  end  was  what  appeared 
to  be  the  urachal  cord.     Immediately  beneath  the  peritoneum  of  the  tumor  were 


544 


THE    UMBILICUS    AND    ITS    DISEASES. 


Nerves 


Tumor 


Bladder 
muscle 


Fig.  236. — A  Diffuse  Neuroma  Forming  a  Mantle  Abound  the  Cavity  of  the  Bladder. 
(After  William  H.  Welch  and  Thomas  S.  Cullen.) 
Surg.  No.  34093.  Service  of  Professor  William  S.  Halsted,  Johns  Hopkins  Hospital.  The  section  has  been 
taken  through  the  top  of  the  bladder  seen  in  Fig.  234.  It  embraces  both  walls  of  the  bladder,  and  near  the  center  the 
slit-like  vesical  lumen  is  visible.  This  photomicrograph  shows  numerous  nerve-trunks  on  the  outer  surface  of  the 
bladder.  The  white  areas  scattered  throughout  the  bladder  muscle  are  also  nerves.  Surrounding  the  bladder  cavity 
is  a  mantle  composed  almost  entirely  of  nerves.  This  nerve  zone  varied  from  1  to  2  cm.  in  thickness.  The  mucosa 
of  the  bladder  in  this  vicinity  was  in  most  places  reduced  to  one  layer  of  epithelial  cells  that  were  cuboid  or  flat.  (Iron- 
.  hematoxylin.     Photomicrograph  by  Mr.  Herman  Schapiro.) 


LARGE    URACHAL   CYSTS.  545 

numerous  small,  tortuous  cords.  The  obliterated  hypogastric  remains  were  unusu- 
ally large'. 

The  ureter  on  the  left  side  was  normal  in  size;  that  on  the  right,  fully  8  mm.  in 
diameter.  It  was  evident  that  this  tumor  either  lay  as  a  cap  on  the  top  of  the  blad- 
der or  that  it  formed  an  integral  part  of  the  bladder-wall.  After  carefully  walling  it 
off,  I  cut  into  it  and  found  that  we  were  dealing  with  a  greatly  thickened  bladder- 
wall.  Fig.  235  shows  the  proximal  portion  of  the  wall  on  section.  The  inner  sur- 
face of  the  bladder  was  thrown  into  folds,  and  its  mucosa  was  exceedingly  thin. 
The  bladder-wall  was  markedly  changed,  being  coarse  in  texture,  due  to  the  cross- 
section  of  many  cords  which  emerged  from  the  surface.  Only  near  the  peritoneal 
surface  was  there  any  semblance  of  normal  bladder  muscle.  The  walls  of  the  blad- 
der were  approximated  with  considerable  difficulty,  and  sutured,  and  a  drain  was 
laid  down  to  the  peritoneum.  After  the  operation  the  boy  did  well  for  several 
hours;  he  then  developed  nausea,  vomiting,  abdominal  distention,  and  tenderness; 
his  temperature  ranged  from  100.4°  to  103.8°  F.  and  his  pulse  was  very  rapid. 

On  April  1st  it  was  deemed  advisable  to  do  an  enterostomy.  He  was  given  a 
few  whiffs  of  gas,  but  died  before  any  operative  procedure  could  be  carried  out. 
Much  to  our  regret  no  autopsy  could  be  obtained,  but  the  abdomen  was  sufficiently 
opened  to  see  that  peritonitis  existed. 

Examination  of  the  portion  of  the  bladder  removed  showed  that  its  walls  varied 
from  1  to  3  cm.  in  thickness,  the  extreme  degree  of  thickening  being  more  marked  in 
the  posterior  vesical  wall  and  at  the  top  of  the  bladder.  Wherever  the  thickening 
was  marked,  this  very  unusual  and  coarse  appearance  was  noted. 

Fig.  236  is  a  photomicrograph  of  a  section  taken  through  the  top  of  the  bladder. 
It  embraces  both  walls  and  the  lumen  of  the  bladder.  On  the  outer  surface  of  the 
bladder  are  a  large  number  of  nerves.  These  represent  the  tortuous  cords  noted  at 
operation.  The  muscular  walls  of  the  bladder  are  still  well  preserved,  but  penetrat- 
ing here  and  there  are  large  nerves.  Separating  the  muscle  from  the  bladder 
mucosa  is  a  zone  consisting  entirely  of  nerve  elements.  In  other  words,  surrounding 
the  bladder  cavity  in  this  region  is  a  mantle  of  nerve  tissue  varying  from  1  to  2  cm. 
in  thickness.  We  are  indebted  to  Mr.  Charles  Miller,  the  technician  in  Professor 
Mall's  department,  for  preparing  many  exquisite  sections  showing  the  appear- 
ances with  the  various  nerve-stains.  These  findings  will  be  reported  in  detail  at 
a  later  date. 

The  bladder  mucosa  in  the  portion  removed  was  in  some  places  composed  of 
several  layers  of  transitional  cells,  but  in  most  places  the  epithelium  was  but  one 
layer  thick  and  almost  flat,  and  the  nerves  came  up  to  and  encroached  upon  the 
epithelium. 

Had  I,  prior  to  operation,  for  a  moment  dreamed  that  this  was  not  a  urachal 
tumor,  'the  bladder  would  have  been  at  once  filled  with  thorium  and  x-rayed. 
Knowing  what  we  do  now,  we  are  not  in  the  least  surprised  that  such  a  bladder  would 
be  very  slow  to  heal  after  being  incised.  The  broad  inner  zone  consisted  almost 
entirely  of  nerves,  and  in  addition  had  a  very  meager  blood-supply. 

This  is  the  only  bladder  tumor  of  this  character  with  which  we  are  familiar;  a 
mistake  in  diagnosis  of  this  kind  will  rarely  occur. 


36 


546  THE    UMBILICUS    AND    ITS    DISEASES. 

TREATMENT  OF  URACHAL  CYSTS. 

A  median  incision,  commencing  just  below  the  umbilicus  and  extending  to  the 
pubes,  will  be  sufficient  to  expose  a  urachal  cyst  of  moderate  size.  As  soon  as  the 
recti  muscles  are  separated,  the  cyst  will  come  into  view.  Sometimes  it  is  infected 
and  shows  signs  of  inflammation.  It  is  usually  loosely  adherent  to  the  peritoneum, 
and  can  be  readily  shelled  out.  Sometimes  it  is  rather  firmly  adherent  to  the 
posterior  surface  of  the  bladder.  In  those  cases  in  which  the  urachus  is  rather  thick 
and  passes  directly  into  the  cyst,  it  is  well  to  treat  it  as  a  pervious  cord  and  to  ligate 
it  with  Pagenstecher  thread  and  cover  this  in  turn  with  catgut,  to  prevent  the 
possible  development  of  a  urinary  fistula  in  the  lower  angle  of  the  abdominal  wound. 

If  the  urachal  cyst  extends  upward  beyond  the  umbilicus,  it  is  wise,  when  making 
the  abdominal  incision,  to  encircle  the  umbilicus,  as  this  is  often  adherent  to  the 
cyst  and  should  be  removed  with  it. 

In  some  cases  it  has  been  found  possible  to  remove  the  cyst  without  opening  the 
abdominal  cavity.  In  others  the  cyst  had  become  adherent  to  the  omentum,  and  it 
was  necessary  to  liberate  the  omental  adhesions  before  the  tumor  could  be  removed. 

When  the  cyst  is  exceptionally  large,  the  peritoneum  has  of  necessity  been 
widely  separated  from  the  anterior  abdominal  wall.  After  operation  the  normal 
intimate  relation  is  usually  restored,  but  that  this  does  not  always  happen  is  evident 
from  Douglas's  case.  After  drawing  off  25  pints  of  clear  fluid,  Douglas  readily 
separated  the  cyst-wall.  The  area  of  peritoneum  separated  from  the  parietes 
extended  from  about  three  inches  above  the  umbilicus  to  the  symphysis.  It  was 
observed  that  the  peritoneum  sank  away  from  the  parietes,  but,  thinking  that  when 
the  abdominal  wound  was  closed  the  intra-abdominal  pressure  would  bring  it  into 
apposition  with  the  abdominal  wall,  Douglas  made  no  effort  to  stitch  it  there.  The 
abdominal  wound  was  closed  in  the  usual  manner  and  a  firm  compress  was  applied. 
The  patient  left  the  operating  room  in  a  remarkably  good  condition.  Twenty-four 
hours  later  her  temperature  was  99.4°  F.,  her  pulse  136,  respirations,  30.  She  was 
nauseated,  vomited  slightly,  and  there  was  some  epigastric  distention.  She  became 
dull  and  roused  only  when  vomiting.  Her  condition  rapidly  grew  worse,  and  she 
died  forty-six  hours  after  operation. 

At  autopsy  the  entire  detached  peritoneum  on  the  right  side  was  found  to  be 
gangrenous.  There  had  been  no  hemorrhage,  but  there' was  a  little  effusion  between 
the  peritoneum  and  abdominal  wall.  The  peritoneal  cavity  contained  a  little 
brown  serous  effusion,  but  no  pus  or  lymph. 

Tait  also  reported  a  death  in  one  of  his  large  cyst  cases.     The  cause  could  not  be- 
ascertained,  as  no  autopsy  was  obtainable. 

As  a  rule,  non-infected  urachal  cysts  can  be  removed  with  little  clanger.  If  very 
large,  it  may  in  rare  instances  be  advisable  merely  to  drain  them  and  allow  the  sac 
to  contract  down  gradually.  It  can  then  be  removed  with  less  danger  of  injury  to 
the  peritoneum.  On  the  other  hand,  the  adhesions  at  the  second  operation  are  liable 
to  be  much  denser. 

Where  the  peritoneum  has  been  widely  denuded,  it  may  be  tacked  to  the  abdomi- 
nal wall  with  several  delicate  catgut  sutures;  or  one  or  two  delicate  protective  drains 
may  be  carried  down  to  the  peritoneum,  not  only  providing  for  the  escape  of  any 
slight  amount  of  fluid  that  may  accumulate,  but  also  allowing  the  air  to  escape  and 
tending  to  make  the  abdominal  walls  flatten  down  on  the  peritoneum. 


LARGE    URACHAL    CYSTS.  547 

DETAILED  REPORT  OF  LARGE,  NON-INFECTED  URACHAL  CYSTS. 

This  list  includes  those  cases  in  which  little  or  no  infection  existed.  Tait,  in  his 
article  published  in  1886,  recorded  a  relatively  large  number  of  cases.  The  majority 
of  these  and  some  others  were  rather  indefinite  and  have  purposely  been  omitted. 

The  cyst  in  Schaad's  case  was  probably  urachal  in  origin,  but  it  was  lined  with 
high  cylindric  epithelium;  and  as  glands  opened  into  it,  its  origin  from  remnants  of 
the  omphalomesenteric  duct  cannot  be  absolutely  excluded. 

A  Urachal  Cyst.  —  Atlee,*  on  opening  the  abdomen  for  the  removal  of 
an  ovarian  tumor  in  a  girl  eighteen  years  of  age,  found  a  urinary  pouch  in  the  linea 
alba.  This  he  accidentally  divided  with  the  knife.  The  abdominal  walls  were 
very  thick,  vascular,  and  remarkably  muscular.  Between  the  muscle  and  the 
peritoneum  he  opened  a  small  cyst  from  which  about  one  ounce  of  yellowish 
liquid,  resembling  ordinary  ascitic  fluid,  escaped.  The  posterior  wall  of  the  sac  was 
cut  through  and  the  peritoneum  opened.  There  were  no  adhesions.  The  bladder 
occupied  the  normal  position.  On  the  sixth  day  the  dressings  were  moist,  and  by 
the  end  of  a  month  Dr.  Fay,  who  looked  after  the  case,  felt  sure  that  the  fluid  was 
urine.  The  patient  was  advised  to  empty  the  bladder  frequently,  and  the  discharge 
soon  ceased. 

"The  only  conclusion  possible  was  that  we  were  dealing  with  a  dilated  urachus, 
which,  although  closed  at  the  umbilicus,  had  from  birth  maintained  a  communica- 
tion with  the  bladder." 

A  Urachal  C  y  s  t  .  f  —  "I.  F.,  aged  six  years;  Newcomerstown,  Ohio. 
Physician,  Dr.  Hosick.  The  patient  had  been  taken  suddenly  sick  about  three 
weeks  before.  The  pain  seemed  to  be  in  the  neighborhood  of  the  appendix,  but 
somewhat  below  McBurney's  point.  Slight  elevation  of  temperature.  Thighs 
flexed.  Amount  of  pain  quite  variable.  Bowels  regular.  No  appetite.  A  little 
before  she  came  to  the  hospital  the  abdomen  became  much  distended  and  painful. 
Pulse  more  rapid.  Temperature,  100°  F.  The  presumptive  diagnosis  had  been 
appendicitis  with  enormous  abscess  formation.  When  the  patient  reached  the 
hospital  (May  7, 1911),  the  abdomen  was  considerably  distended  and  tender  through- 
out, and  with  distinct  fluctuation.  There  was  perhaps  a  little  more  tenderness  in 
the  appendix  region  than  elsewhere,  but  this  was  not  marked.  Diagnosis,  very 
doubtful,  but  the  case  clearly  one  for  exploration. 

"When  the  patient  was  under  the  anesthetic  I  could  determine  nothing  more 
about  the  case.  No  lump  in  the  region  of  the  appendix.  Made  the  usual  median 
incision.  As  soon  as  the  incision  was  made  there  was  an  escape  of  a  large  amountof 
rather  thin,  yellow,  odorless  fluid.  The  opening  was  enlarged,  and  the  cavity  thor- 
oughly flushed  out,  the  water  bringing  out  a  large  amount  of  what  seemed  to  be 
necrotic  lymph.  The  cavity  was  found  to  be  bounded  below  by  the  pelvis,  above 
by  probably  the  transverse  colon  and  the  stomach.  It  extended  on  each  side  clear 
to  the  flanks.  The  intestines  were  crowded  back  by  the  posterior  wall  of  the  cyst. 
The  uterus  in  this  case  could  be  readily  felt,  though  infantile  in  size,  below  the 
membrane.  Introduced  drainage,  with  partial  closure  of  the  incision.  The  patient 
made  a  smooth  convalescence  and  returned  home  in  the  usual  time,  with  distinct 
warning  as  to  the  probability  of  a  hernia. 

*  Atlee,  Washington  L. :  Ovarian  Tumors,  Philadelphia,  Lippincott,  1873,  50. 

t  Baldwin:   Large  Cysts  of  the  Urachus.     Surg.,  Gyn.  and  Obst.,  1912,  xiv,  636. 


548  THE    UMBILICUS    AND    ITS    DISEASES. 

"  September  3,  1911,  patient  returned  with  her  mother  because  they  had  noticed 
a  beginning  hernia.  The  hernia  was  operated  upon  the  next  day.  I  made  an 
incision  directly  through  the  old  scar,  dissecting  down  very  cautiously,  as  I  expected 
to  find  extensive  adhesions.  On  finally  opening  the  peritoneum  I  found  that  the 
abdominal  contents  were  in  every  respect  absolutely  normal,  except  for  two  cobweb 
adhesions  of  the  omentum  to  the  anterior  abdominal  wall.  The  appendix  was 
brought  up  and  found  to  be  entirely  normal;  was  removed  on  general  principles. 
Pelvic  organs  normal.  In  fact,  had  one  not  familiar  with  the  previous  history  of 
the  case  made  the  operation,  he  would  have  found  nothing  whatever  to  suggest  any 
previous  trouble  in  the  abdomen.  In  other  words,  the  sac  had  absolutely  disap- 
peared. The  bladder,  however,  seemed  to  be  a  little  higher  up  than  usual,  though 
even  that  was  not  positive." 

Large  Urachal  Cysts.  —  Dr.  Bantock*  said  he  was  sure  he  was 
expressing  the  sentiments  of  every  one  present  when  he  desired  to  offer  the  thanks  of 
the  Society  to  their  President  [Lawson  Tait]  for  the  very  remarkable  and  interesting 
paper  which  he  had  just  read.  The  cases  were  of  remarkable  interest,  but  he  feared 
there  was  no  one  who  could  discuss  the  subject  from  experience.  The  paper  was 
one  for  future  perusal  and  careful  study.  He  at  least  was  not  prepared  to  discuss 
it,  but  he  thought  he  might  refer  to  two  cases  of  which  he  was  reminded  by  some  of 
the  cases  related  by  the  President. 

The  first  case  was  that  of  a  married  woman,  aged  thirty,  the  mother  of  two  chil- 
dren. On  dividing  the  parietes,  Bantock  opened  into  a  cyst  containing  25  pints  of 
a  thick,  grumous  fluid,  with  a  very  decided  biliary  tinge.  When  the  whole  of  the 
fluid  was  removed,  the  cyst  was  found  to  be  unilocular,  and  looking  down  into  the 
pelvis  was  like  looking  into  one's  hat,  so  completely  did  the  walls  of  the  cyst  line  the 
pelvic  cavity.  After  separating  what  appeared  to  be  cyst-wall  from  the  parietes  on 
each  side,  and  cutting  away  what  was  thus  separated,  recognizing  the  hopelessness 
of  proceeding  further,  he  washed  out  the  cyst  with  a  solution  of  iodin  and  closed  the 
wound,  leaving  a  drainage-tube  passing  down  to  the  bottom  of  the  pouch.  Although 
the  separation  of  what  was  taken  as  cyst-wall  was  carried  beyond  the  umbilicus,  the 
peritoneal  cavity  was  not  opened.  A  thick,  pultaceous  fluid  of  the  color  of  mustard 
came  from  the  cavity  for  many  weeks,  but  the  patient  was  discharged  quite  well  at 
the  end  of  about  two  months.  Bantock  had  lately  seen  this  patient  in  perfect 
health.  He  adds  that  the  source  of  the  brilliant  yellow  color  of  the  discharge  was 
still  a  puzzle  to  him. 

The  second  case  was  that  of  a  married  woman,  thirty-seven  years  of  age,  the 
mother  of  three  children.  The  history  told  that  she  was  taken  ill  on  January  10th 
with  violent  sickness  and  pain  all  over  the  stomach.  She  was  laid  up  and  became 
feverish;  the  pain  being  severe  for  five  days  and  the  sickness  for  two  days.  The 
abdomen  gradually  got  larger,  and  about  the  end  of  February  she  was  tapped  of 
rather  more  than  half  a  gallon  of  a  thickish,  pale-yellowish  fluid.  In  about  a  month 
more  she  was  tapped  again  to  the  extent  of  three  pints  of  a  thicker  fluid,  and  recom- 
mended to  apply  poultices.  Shortly  after  this  the  puncture-hole  opened  and  dis- 
charge came  away.  She  then  presented  herself  at  the  out-patient  department  of  the 
Samaritan  Hospital,  under  the  care  of  Dr.  Amand  Routh,  with  whom  Bantock  saw 
her.  There  was  then  a  fistulous  opening  about  two  inches  below  the  umbilicus,  in 
the  middle  line,  and  an  ordinary  surgical  probe  passed  in  for  its  whole  length.  She 
*  Bantock:  From  Tait's  article,  Brit.  Gyn.  Jour.,  1886-87,  ii,  348. 


LARGE    URACHAL    CYSTS.  549 

was  admitted  into  the  hospital  on  July  20th,  and  Bantock  thought  he  had  to  deal 
with  a  multilocular  tumor  of  which  a  central  cyst  had  suppurated,  as  on  withdrawing 
the  probe  no  discharge  followed.  On  July  27th  he  divided  the  parietes  by  a  double 
elliptic  incision,  with  the  view  of  cutting  out  the  fistulous  tract,  and  was  not  a  little 
surprised  to  find,  on  completing  the  division  on  one  side,  that  he  had  opened  directly 
into  a  unilocular  cyst  containing  from  three  to  four  pints  of  a  purulent-looking  fluid. 
On  further  examination  he  found  the  same  condition  of  things  as  in  the  first  case, 
and,  recognizing  the  inadvisability  of  proceeding  further,  he  thoroughly  washed  out 
the  cavity  with  plain  warm  water  and  closed  the  wound,  leaving  in  a  glass  drainage- 
tube.  The  patient  presented  herself  at  the  hospital  two  or  three  weeks  before  the 
meeting  of  the  society  and  was  in  perfect  health.  In  this  case  the  uterus  was  low 
down,  pressed  forward,  and  fixed.  Bantock  said  that  he  was  as  much  at  a  loss  to 
explain  the  relations  and  origin  of  this  cyst  as  in  the  first  instance,  but  he  thought 
they  were  worthy  of  being  related  in  connection  with  the  very  remarkable  cases 
read  by  the  President. 

Probably  a  Urachal  Cyst.  —  Bryant,*  in  discussing  Doran's  paper, 
reported  two  cases.  In  Case  1,  on  operating  on  what  had  been  diagnosed  as  an 
ovarian  cyst,  he  suddenly  opened  into  a  cyst  from  which  serosanguineous  fluid 
escaped.  This  was  in  front  of  the  peritoneum,  and  was  with  difficulty  separated 
from  the  bladder.  When  this  had  been  done,  the  cyst  came  away  in  his  hand,  and 
it  was  clear  that  it  had  no  pedicle  nor  any  connection  with  the  broad  ligament. 

A  Cystic  Urachus.  —  Carroll's!  patient  was  a  woman  thirty-four  years 
old.  She  had  been  well  until  twenty-three.  After  that  she  had  had  attacks  of 
abdominal  pain,  loss  of  weight,  and  on  one  occasion  inflammation  of  the  bladder. 

On  examination  an  induration  was  found  extending  from  the  umbilicus  two  to 
three  inches  to  the  right,  and  downward  for  three  or  four  inches.  The  tumor  was 
apparently  too  near  the  umbilicus  to  be  of  appendiceal  origin. 

Roswell  Park  made  a  median  incision  below  the  umbilicus.  The  tissues  were 
very  dense  and  difficult  to  cut.  A  sac  was  opened  and  fluid  escaped.  The  incision 
was  enlarged,  and  a  finger  introduced.  The  tumor  was  found  to  be  a  cystic  urachus. 
A  connection  with  the  bladder  could  be  traced,  but  a  probe  could  not  be  passed. 
The  connection  was  tied  off  and  the  cyst  dissected  out.  There  were  a  number  of 
adhesions  between  the  tumor  and  the  omentum.  The  patient  made  a  good  recov- 
ery. "The  probable  explanation  of  the  attacks  seemed  to  be  an  oozing  of  urine 
into  the  upper  or  cystic  part  of  the  urachus,  and  as  there  was  no  egress  for  the  fluid 
once  gathered,  it  was  absorbed  into  the  system,  causing  a  toxemia." 

A  Large  Cyst  of  the  Urachus.  £  —  The  patient  was  a  girl,  twenty 
years  of  age.  The  tumor  had  first  been  noticed  a  year  before  admission.  It  had 
increased  greatly  in  size  in  the  last  four  months.  It  had  commenced  as  a  painful 
point  in  the  right  iliac  fossa.  On  account  of  the  patient's  emaciation  and  the 
increase  in  abdominal  girth  the  physician  had  diagnosed  tuberculous  peritonitis. 
On  admission  there  was  great  abdominal  distention,  evidently  due  to  fluid. 

Operation. — An  incision  was  first  made  as  far  as  the  umbilicus,  and  was  extended 
upward  to  the  xiphoid.  The  tumor  was  adherent  at  the  umbilicus.  The  pedicle 
was  attached  to  the  summit  of  the  bladder.     It  had  no  lumen  and  did  not  open  into 

*  Bryant,  T. :  Brit,  Med.  Jour.,  1898,  i,  1390. 

f  Carroll,  Jane  W.:  Buffalo  Med.  Jour.,  1895-96,  xxxv,  869. 

1  Cotte  et  Delore:    Gros  kyste  de  l'ouraque.     Lyon  med.,  1905,,  cv,  373. 


550  THE    UMBILICUS    AND    ITS    DISEASES. 

the  bladder.  The  uterus,  tubes,  and  ovaries  were  normal.  The  cyst  was  unilocular 
and  contained  between  eight  and  nine  liters  of  brown,  hemorrhagic  fluid.  This  was 
not  examined  microscopically.  The  inner  lining  of  the  cyst  was  made  up  of  inflam- 
matory tissue.  On  the  cut  surface  the  urachus  was  recognized  as  a  cord.  The 
authors  say  that  the  cyst  had  developed  from  the  urachus.  The  patient  made  a 
good  recovery. 

A  Urachal  Cyst  Simulating  an  Appendicular  Ab- 
scess.* —  "The  patient,  aged  seventeen  and  a  half  years,  unmarried,  applied  to 
Dr.  R.  Drummond  Maxwell  at  the  out-patient  department  of  the  Samaritan  Free 
Hospital  on  July  16,  1908.  She  complained  of  tenderness  and  swelling  in  the  right 
iliac  fossa,  associated  with  a  history  of  a  sudden  attack  of  pain  in  that  region  a  month 
previously,  and  she  was  admitted  into  my  ward  at  once.  After  admission  I  found 
that  the  relations  of  the  swelling  to  adjacent  organs  could  not  well  be  defined  until 
I  examined  the  patient  with  the  aid  of  anesthesia,  under  circumstances  presently  to 
be  explained.  The  patient's  mother  informed  me  that  the  catamenia  were  estab- 
lished at  the  age  of  fourteen  years,  without  pain  or  constitutional  disturbance. 
The  periods  were  always  scanty  and  attended  with  very  little  pain,  and  the  interval 
was  about  five  weeks.  The  patient  had  never  suffered  from  any  neurosis  before,  at, 
or  after  puberty.  On  June  16th,  one  calendar  month  before  admission,  the  menstrual 
flow  appeared  as  usual,  but  was  accompanied  by  violent  pain  never  experienced 
before.  The  pain  continued  for  two  days  and  then  it  abated.  The  patient  at  once 
resumed  her  work,  but  the  pain  returned  two  days  later  and  obliged  her  to  take  to 
her  bed  again.  During  the  whole  of  the  week  before  admission  she  was  quite  inca- 
pable of  attending  to  her  duties.  Roughly  speaking,  as  regards  what  could  be  made 
out  before  anesthesia  was  employed,  there  was  a  fairly  defined,  almost  spheric 
swelling  in  the  right  iliac  fossa,  slightly  movable  and  tender  to  the  touch.  There  was 
resonance  on  percussion  over  its  outer  aspect.  The  lower  part  of  the  swelling  could 
be  defined  on  rectal  examination.  I  refrained  from  making  a  vaginal  exploration 
until  a  consultation  was  held.  Then  it  was  found  that  the  vagina  was  barely  two 
inches  deep.  A  kind  of  dimple  could  be  defined  at  the  blind  extremity  toward  the 
right.  The  tumor  did  not  bulge  into  the  vagina.  At  the  lower  limits  of  the  swell- 
ing was  a  tuberosity  which  lay  behind  the  vagina  and  in  front  of  the  rectum.  The 
temperature  and  pulse  were  low.  The  patient  had  never  been  laid  up  with  any 
severe  illness.  Before  the  arrested  development  of  the  vagina  had  been  detected, 
appendicular  abscess  was  suspected,  but  after  the  examination,  hematometra  or 
hematosalpinx  seemed  equally  probable.  On  July  21st  the  period  began,  as  usual, 
about  five  weeks  after  that  which  had  preceded  it.  I  found  that  there  was  no  pal- 
pable increase  of  pain  or  tenderness  in  the  tumor  nor  any  appreciable  increase  or 
decrease  in  size.  The  flow  was  unusually  free.  I  decided  to  examine  the  patient 
under  anesthesia  during  the  period  in  order  to  discover  the  channel  which  trans- 
mitted the  menstrual  blood  into  the  vagina,  and  for  other  manifest  reasons. 

"Examination  under  Anesthesia. — The  perineum  was  markedly  deep,  so  that  the 
anterior  commissure  lay  far  forward.  The  labia,  clitoris,  and  meatus  urinarius  were 
normally  developed.  There  appeared,  on  the  other  hand,  to  be  Ao  hymen  nor  was 
there  the  least  trace  of  carunculse." 

"The  vagina  formed  a  blind  pouch  about  two  inches  deep.  The  rugae  were 
prominent. 

*Doran,  Alban  H.  G.:  The  Lancet,   1909,  i,  1304. 


LARGE    URACHAL    CYSTS. 


551 


Ut? 


"The  vaginal  pouch  was  distinctly  deeper  on  the  right  side,  whence  dark  men- 
strual blood  was  seen  to  issue.  On  stretching  the  adjacent  mucosa  with  the  fingers, 
a  crescentic  fold  with  the  concavity  toward  the  left  was  detected.  It  covered  the 
aperture  whence  proceeded  the  blood.  A  uterine  sound  could  be  passed  into  this 
aperture  and  pushed  onward  for  three  inches  upward,  backward,  and  a  little  to  the 
right,  closely  following  the  outer  limits  of  the  lower  pole  of  the  swelling,  as  could 
easily  be  defined  on  digital  exploration  from  the  rectum  (Fig.  237).  On  bimanual 
palpation  the  swelling  was  found  to  be  a  well-circumscribed  tumor,  firm,  pushed  a 
little  downward,  yet  even  then  its  lower  pole  did  not  bulge  into  the  vagina,  but  passed 
behind  it.  The  tuberosity  in  the  rectovaginal  septum,  discovered  at  the  previous 
examination,  lay  to  the  left  of  the  menstruating  tract.  It  felt  like  a  small  cervix. 
The  nature  of  the  case  remained  obscure.  I  kept  the  patient  at  rest  for  a  week. 
The  period  ceased,  and  the  tumor  remained  stationary.  There  was  one  sharp 
attack  of  local  pain  on  July  28th,  with- 
out any  rise  of  pulse  or  temperature." 

"Operation. — On  July  29th  I  oper- 
ated with  the  assistance  of  Dr.  R.  V.  G. 
Monckton,  Dr.  S.  H.  Belfrage  adminis- 
tering ether  and  chloroform.  I  made  an 
incision  in  the  middle  line.  The  parietes 
were  unusually  vascular.  After  separat- 
ing the  recti  I  came  across  a  thick  mem- 
brane of  doubtful  character,  and  lower 
clown  I  exposed  the  wall  of  the  bladder, 
which  extended  for  quite  two  inches 
above  the  pubes.  The  membrane  was 
cut  through,  and  about  half  a  pint  of  a 
perfectly  clear  fluid  was  removed;  un- 
fortunately, none  was  preserved.  The 
fluid  lay  in  a  cyst  behind  the  recti  and 
anterior  to  the  parietal  peritoneum,  the 
membrane  through  which  I  had  made 

the  incision  being  the  anterior  portion  of  the  cyst-wall.  The  cyst  was  connected 
with  the  bladder  by  a  thick  cord  half  an  inch  in  length.  The  upper  limits  of  the 
cyst  lay  close  below  the  umbilicus.  In  exploring  the  upper  end  of  the  tumor  I 
laid  open  the  peritoneal  cavity.  The  omentum  adhered  to  the  peritoneum,  invest- 
ing the  back  of  the  cyst  in  this  region.  The  intestines  seemed  healthy;  there  was 
no  evidence  of  tuberculous  disease,  no  free  fluid,  and  no  intraperitoneal  tumor. 
Lower  down  some  coils  of  ileum  adhered  to  the  parietal  peritoneum  behind  the  tumor. 
"I  endeavored  to  define  the  relations  of  the  cyst  to  the  genito-urinary  tract.  A 
catheter  was  passed  into  the  bladder,  and  a  few  ounces  of  urine  were  drawn  off. 
There  was  no  communication  between  the  cavity  of  the  bladder  and  the  cavity  of  the 
cyst;  the  thick  cord  between  the  two  was  clearly  a  portion  of  the  urachus,  and  I 
observed  that  it  ran  into  and  not  over  the  cyst-wall. 

"As  might  have  been  suspected  from  what  could  be  defined  before  the  operation, 
the  cyst  lay  to  the  right  of  the  middle  line.  On  pressing  against  its  wall  on  the  right 
interiorly,  from  the  inner  side  I  detected  a  fusiform  body  like  a  uterine  cornu  or  a 
small  but  entire  virgin  uterus,  lying  in  the  position  of  the  menstruating  tract  along 


Fig.  237. — Diagram  Showing  the  Arrested  Devel- 
opment of  the  Genital  Tract  and  the  Rela- 
tion of  the  Malformed  Parts  to  the  Cyst  of 
the  Urachus.     (After  A.  Doran.) 
Vg,  vagina,  its  blind  end  rising  higher  on  the  right 
side  than  on  the  left;   VI,  valvular  fold,  through  which 
a  sound  (<S>)  passes  into  Rt.  Ut.,  the  right  cornu;  Ov,  right 
ovary;  Lft.  Ut.,  solid  body,  probably  left  cornu;  the  dot- 
ted lines  indicate  a  band,  not  clearly  definable,  connect- 
ing it  with  the  right  cornu. 


552 


THE    UMBILICUS    AND    ITS    DISEASES. 


*7 


I 


which  a  sound  had  been  passed  a  week  before.  Above  this  body  thickened  tissue 
could  be  felt — apparently  a  small  ovary.  The  tuberous,  cervix-like  body  already 
mentioned  could  be  plainly  defined  through  the  walls  of  the  lowest  part  of  the  cyst. 
When  thus  explored,  it  was  found  to  be  a  distinct,  fairly  movable  structure — the  left 
ovary  or  uterine  cornu.  On  further  palpation  through  the  cyst-wall  the  pelvic 
cavity  felt  quite  free  from  any  tumor  or  deposit.  There  certainly  was  no  such  thing 
as  a  collection  of  retained  menstrual  blood. 

"  At  this  stage  of  the  operation  it  became  evident  that  the  swelling,  which  disap- 
peared entirely  when  I  opened  the  cavity  full  of  fluid,  was  a  urachal  cyst.  The 
swelling — in  other  words,  the  cyst — had  been  the  cause  of  all  the  patient's  recent 
trouble.  As  there  was  no  trace  of  a  hematometra  or  hematosalpinx,  I  did  not  feel 
justified  in  dissecting  in  the  dark  behind  the  cyst,  amid  deformed  structures,  in 

very  uncertain  relations  to  ureters, 
blood-vessels,  etc.,  merely  to  make 
out  the  extent  of  arrested  develop- 
ment of  the  uterus  and  appendages. 
It  was  with  the  cyst,  therefore, 
alone  that  I  had  to  deal.  I  knew 
of  several  objections  to  the  draining 
of  a  urachal  cyst,  nor  could  I  dis- 
sect away  its  outer  wall,  since,  as 
I  have  just  observed,  its  positive 
relations  to  malformed  structures 
were  very  uncertain.  For  these 
reasons  I  simply  trimmed  away  as 
much  of  the  lining  membrane  as 
could  be  safely  removed.  Then  I 
cautiously  passed  several  fine  cat- 
gut sutures  along  the  substance  of 
the  outer  wall  and  tied  them,  so 
that  the  cyst  cavity  was  closed  in. 
This  outer  wall  was  the  muscular 
sheath  of  the  urachus  abnormally 
thickened,  so  that  the  manceuver 
just  described  was  easy  and  nothing 
was  caught  up  behind  the  cyst.  I  transfixed  the  segment  of  the  urachus,  which  ran 
between  the  lower  limits  of  the  cyst  and  the  bladder,  with  a  fine  linen  suture  and 
tied  it  on  both  sides.  It  was  then  divided  between  the  cyst  and  the  ligature.  As 
will  be  explained  presently,  it  is  fortunate  that  I  transfixed  the  urachus  instead  of 
tying  a  single  ligature  around  it  as  though  it  were  an  artery.  I  kept  the  portion 
attached  to  the  cyst  for  microscopic  examination.  Lastly,  the  sheaths  of  the  recti 
were  united  with  interrupted  fine  linen  sutures  and  the  integuments  closed  with 
interrupted  silkworm-gut. 

"During  the  summer  vacation  Dr.  Maxwell  took  charge  of  the  patient  in  my 
absence.  He  reported  that  up  to  the  day  of  her  discharge  at  the  end  of  August 
there  was  no  sign  of  leakage  of  urine  through  the  wound  nor  any  show  of  blood." 

Microscopic  Examination  of  the  Cord  Between  the  Cyst  and  the  Bladder. — A 
section  of  the  cord-like  structure  which  ran  on  the  surface  of  the  parietal  peritoneum 


Fig.    238. — Section   of   the   Segment   op   Urachus  which 
Passed  Between  the  Bladder  and  the  Cyst-wall,  as 
Seen  Under  a  Low  Power.     (After  A.  Doran.) 
The  canal  is  quite  unobstructed  and  lined  with  transitional 
epithelium;  the  muscular  coat  is  very  thick.     (In  our  reproduc- 
tion part  of  the  detail  has  been  lost — T.  S.  C.) 


LARGE    URACHAL    CYSTS.  553 

between  the  fundus  of  the  bladder  and  the  cyst  was  made  at  the  Royal  College  of 
Surgeons  of  England.  There  could  be  no  doubt  that  it  was  a  portion  of  the  urachus. 
Mr.  S.  G.  Shattock  reported  that  the  canal  was  quite  patulous  and  lined  with  perfect 
transitional  epithelium  of  the  bladder  type.  The  lumen  was  free  from  catarrhal  or 
other  morbid  products.  The  muscular  coat  was  abnormally  thick,  but  showed  no 
evidence  of  inflammation  or  edema.  Its  inner  portion  was  mostly  made  up  of  cir- 
cular, and  its  outer  portion  of  longitudinal,  fibers,  but  there  was  some  irregularity  in 
the  direction  of  the  fibers  in  both  portions.  Some  subperitoneal  fat  was  intimately 
connected  with  the  periphery  of  the  urachus.  The  appended  reproduction  of  a 
photomicrograph  (Fig.  238)  shows  the  above-described  appearance  of  the  urachus  as 
seen  under  the  microscope. 

On  p.  635  I  have  recorded  another  interesting  case  of  Doran's — a  cystic  sarcoma 
of  the  urachus. 

A  Large  Cyst  of  the  Urachus.  —  Dossekker*  reports  the  case  of  a 
woman,  born  in  1850.  When  forty  years  of  age  a  tumor  the  size  of  a  small  fist  was 
found  to  the  right  of  the  uterus.  She  had  various  abdominal  symptoms,  and  finally 
was  sent  to  a  sanitarium.  When  forty-two  years  of  age  she  was  admitted  under  the 
care  of  Kronlein.  She  looked  very  pale.  The  abdomen  was  markedly  distended, 
as  with  a  pregnancy  at  the  ninth  month.  There  was,  in  addition,  a  distention  at  the  - 
umbilical  region,  with  definite  fluctuation.  The  diagnosis  made  was  ovarian  cyst, 
possibly  from  the  right  side,  with  hemorrhage  into  the  cyst,  and  probably  torsion  of 
the  pedicle. 

Operation. — An  incision  was  made  from  the  umbilicus  to  the  symphysis.  As 
soon  as  the  abdominal  walls  were  cut  through  the  knife  entered  a  cyst  cavity.  The 
wall  of  the  cyst  was  intimately  attached  to  the  abdominal  wall,  and  a  large  quantity 
of  thin,  hemorrhagic  fluid  escaped.  This  was  not  sticky  and  had  no  odor.  It 
amounted  to  between  three  and  four  liters.  The  tumor  was  gradually  shelled  out, 
with  little  or  no  hemorrhage,  and  the  abdominal  cavity  proper  was  not  opened.  The 
cyst  did  not  extend  into  the  pelvis,  but  reached  as  far  as  the  top  of  the  bladder.  At 
no  point  was  the  peritoneum  opened.  In  other  words,  the  large  cyst  with  its  con- 
tents lay  between  the  abdominal  wall  and  the  parietal  peritoneum.  The  patient 
made  a  splendid  recovery.  Examination  later  showed  that  the  uterus  and  left  ovary 
were  normal.     The  right  ovary  could  not  be  outlined. 

Dossekker,  after  discussing  the  various  points  of  interest,  says  that  on  histologic 
examination  the  wall  was  found  to  consist  chiefly  of  dense  connective  tissue.  The 
inner  surface  in  most  places  was  without  any  epithelial  lining,  but  at  some  points 
this  was  intact.  It  consisted  of  a  high,  many-layered,  so-called  transitional  epithe- 
lium. The  basal  nuclei  were  elongate  or  oval ;  the  peripheral  were  more  roundish  or 
flat  in  form.  The  epithelium  corresponded  in  character  to  that  of  the  bladder,  and 
agreed  with  the  description  given  by  Luschka  of  the  epithelium  lining  the  canal  of 
the  urachus. 

A  Cyst  of  the  Urachus.  —  On  page  182  Douglasf  describes  the  case  of 
"  Mrs.  C,  aged  thirty-six,  married  eleven  years,  but  sterile.  The  family  and  personal 
history  is  good;  she  has  always  enjoyed  good  health,  but  has  never  been  robust. 
Menstruation  has  been  scanty  and  painful,  but  regular;  she  has  suffered  with  con- 

*  Dossekker:     Klin.   Beitrag  zur  Lehre  von  den  Urachuscysten.     Beitrage  z.  klin.   Chir., 
1893,  x,  102. 

t  Douglas,  Richard:  Trans.  Amer.  Assoc,  of  Obstet.  and  Gynecologists,  1897,  x,  177. 


554  THE    UMBILICUS    AND    ITS    DISEASES. 

stipation,  but  the  kidneys  have  acted  freely  and  normally  until  recently.  About 
eighteen  months  ago  she  observed  a  swelling  in  the  lower  portion  of  the  abdomen, 
rather  more  prominent  on  the  right  side.  The  enlargement  was  soft  and  painless. 
It  grew  slowly  and  did  not  materially  show  until  the  last  four  months,  within  which 
time  its  growth  has  been  rapid,  chiefly  to  the  right  side.  She  has  suffered  from 
backache,  some  loss  of  flesh,  slight  cough,  and  decided  digestive  disorders.  There 
has  been  but  little  pain  or  tenderness  from  the  tumor,  and  no  history  indicating 
local  peritoneal  inflammation.  The  bladder  has  been  somewhat  disturbed,  its  action 
frequent,  but  the  urine  normal.  She  now  complains  more  particularly  of  vomiting 
after  eating  and  a  sense  of  weight  and  heaviness  in  the  epigastric  region.  Of  late 
she  has  grown  nervous  and  suffers  from  insomnia." 

"Physical  Examination. — -The  abdomen  presented  a  very  peculiar  appearance. 
It  was  symmetrically  distended  to  about  the  size  of  a  seven  months'  pregnancy,  the 
greatest  enlargement  being  on  the  right  side;  the  veins  were  not  enlarged,  the  skin 
was  white  and  anemic-looking.  By  palpation  the  irregular  swelling  could  be  out- 
lined. The  tumor  seemed  to  lie  in  the  lower  zone  and  the  right  half  of  the  abdomen. 
It  was  soft,  elastic,  fluctuant  and  compressible.  It  was  not  movable;  there  were  no 
irregularities  or  bosses  upon  it ;  its  surface  was  smooth;  palpation  was  painless;  the 
abdominal  walls  did  not  appear  to  glide  freely  over  the  surface  of  the  tumor.  There 
was  dulness  upon  percussion  over  the  entire  tumor,  yet  that  dulness,  as  was  repeat- 
edly remarked  during  examination,  was  not  the  characteristic  flatness  noted  in 
ovarian  cystoma.  The  dulness  was  absolute  low  down,  but  in  the  region  of  the 
umbilicus  and  beyond,  the  note  became  more  resonant.  Auscultation  negative. 
Vaginal  examination  showed  the  uterus  small,  retroflexed,  and  rather  low  in  the 
pelvis ;  vaginal  vault  encroached  upon  by  an  elastic,  fluctuant  swelling.  The  weight 
of  the  evidence  was  in  favor  of  the  diagnosis  of  ovarian  cystoma.  The  following 
peculiarities,  however,  were  remarked  upon,  and  were  of  such  importance  in  our 
judgment  as  to  render  questionable  the  nature  of  the  case.  The  appearance  of  the 
abdomen  was  not  such  as  is  usually  noted  in  ovarian  cystoma.  While,  of  course, 
we  appreciate  that  the  shape  of  the  abdomen  varies  greatly,  yet  in  a  cyst  so  distinctly 
unilocular  as  this  appeared  to  be,  and  lying  so  superficially,  one  would  expect  to  find 
the  abdomen  rising  abruptly  from  the  symphysis;  that  is,  the  tumor  forming  a  dis- 
tinct angle  with  the  abdominal  plane.  In  this  case  the  abdomen  looked  more  like 
one  distended  by  ascitic  fluid,  rather  flat  upon  the  upper  surface,  and  widely  bulging 
upon  the  right  flank.  The  next  peculiar  physical  sign  was  the  character  of  the 
percussion  dulness. 

"  Operation. — An  incision  was  made  in  the  middle  line,  and  in  going  through  the 
linea  alba  and  transversalis  fascia  I  came  upon  the  red,  congested  cyst-wall,  which 
I  at  first  thought  was  the  peritoneum  inflamed.  I  now  aspirated  the  cyst  and  drew 
off  25  pints  of  clear  fluid.  An  examination  of  the  collapsed  sac  soon  convinced  me 
that  I  was  not  in  the  peritoneal  cavity,  and  that  I  was  dealing  with  a  cyst  of  the 
urachus.  Its  attachment  was  not  very  intimate,  and  its  enucleation  was  readily 
accomplished.  Only  slight  hemorrhage  attended  its  separation.  As  I  removed  the 
sac  I  recognized  that  I  was  working  entirely  outside  of  the  peritoneum.  The 
viscera  could  be  felt  through  the  peritoneum.  The  sac  dipped  down  into  the  true 
pelvis  in  front  of  the  uterus,  depressing  and  retroflexing  it.  There  was  no  apparent 
attachment  of  the  sac  of  a  ligamentous  character  to  the  bladder.  Indeed,  the  cyst 
lay  between  the  peritoneum  and  the  transversalis  fascia,  with  no  special  attachment 


LARGE    URACHAL    CYSTS.  555 

beyond  a  universal  adhesion  to  all  surrounding  parts.  The  area  of  the  peritoneum 
separated  from  the  parietes  extended  from  about  three  inches  above  the  umbilicus 
to  the  symphysis,  and  from  two  inches  to  the  left  of  the  linea  alba  and  through  the 
lumbar  and  iliac  regions  of  the  right  side.  As  there  was  no  bleeding  of  consequence, 
we  now  prepared  to  close  the  abdominal  wound.  It  was  observed  that  the  peri- 
toneum sank  away  from  the  parietes,  but  thinking  that,  when  the  abdominal  wound 
was  closed,  the  force  of  intra-abdominal  pressure  would  bring  it  in  apposition  with 
the  wall,  no  effort  was  made  to  stitch  it  there.  The  abdominal  wound  was  closed  in 
the  ordinary  way.  A  good  compress  was  applied  over  the  abdomen,  and  a  snugly- 
fitting  bandage  adjusted. 

"  The  patient  sustained  but  little  shock  from  the  operation  and  was  placed  in  bed 
in  remarkably  good  condition.  The  fluid  removed  measured  25  pints,  was  of  a  pale 
green  color,  and  a  few  flocculi  were  observed  in  it.  I  regret  to  say  that  it  was  care- 
lessly thrown  away  without  being  submitted  to  chemical  and  microscopic  tests. 
The  sac  was  composed  of  a  thin,  fibrous  material,  showing  no  evidence  of  muscular 
structure,  and  almost  transparent;   it  was  removed  without  tearing. 

"The  patient  was  operated  upon  on  June  20th  at  1 1  o'clock.  Twenty-four  hours 
after  the  operation  the  pulse  was  136,  respiration  30,  temperature  99.4°  F.  She  was 
nauseated  and  had  vomited  slightly;  there  was  some  epigastric  distention;  she  had 
slept  but  little;  the  bowels  had  not  moved,  although  active  efforts  were  employed; 
the  kidneys  had  acted  sufficiently,  36  ounces  of  urine  having  been  voided  since  the 
operation.  The  patient  now  became  very  dull,  inclined  to  sleep,  was  roused  only 
when  vomiting;  the  vomiting  was  of  regurgitant  character,  without  apparent  effort; 
the  matter  ejected  had  that  ugly  green  color  that  we  so  much  dislike  to  see.  Her 
condition  grew  rapidly  worse,  the  pulse  became  more  frequent,  the  temperature 
reached  102°  F.     She  died  at  10  a.  m.,  forty-six  hours  after  operation. 

"Autopsy. — The  entire  detached  peritoneum  on  the  right  side  was  gangrenous. 
There  was  no  hemorrhage,  and  but  very  little  effusion  between  the  peritoneum  and 
wall.  There  was  a  little  brown,  serous  effusion  in  the  peritoneal  cavity,  no  pus  nor 
lymph.  Death  was  due  undoubtedly  to  sapremia.  The  detached  peritoneum  was 
not  forced  against  the  abdominal  wall,  as  I  had  supposed  it  would  be,  but  hung 
loosely,  leaving  quite  a  space  between.  This  peritoneum  was  deprived  of  its  nutri- 
tion, and  had  simply  died  from  starvation." 

Cysts  of  the  Urachus.*  —  Ferguson  says:  "  I  do  not  feel,  however, 
as  has  been  stated  by  Tait,  that  extraperitoneal  tumors  in  that  region  are  all  de- 
rived from  the  urachus.  Tait's  dictum  was  based  on  two  cases  submitted  to  opera- 
tion, both  of  which  resulted  in  death,  in  neither  of  which  was  there  a  postmortem 
examination,  and  in  both  of  which  the  reported  character  of  the  cystic  contents 
would  justify  the  hypothesis  entertained  by  some  that  cysts  originating  in  the 
pelvic  region  may  develop  upward  and  forward  in  such  a  manner  and  way  as  to 
separate  the  peritoneum  from  the  anterior  abdominal  wall,  and  thus  become  extra- 
peritoneal. It  is  my  conviction  that  I  have  seen  at  least  one  case  of  that  character 
— one  which  grew  to  great  dimensions  and  was  cured  over  twenty-five  years  ago  by 
excision  of  some  of  the  anterior  portion  of  the  sac,  and  'suture  puckering'  of  the 
opening  thus  made,  with  drainage  of  the  remainder,  enucleation  of  the  entire  sac 
seeming  too  large  an  undertaking. 

"In  June,  1898,  the  patient,  a  man  aged  about  forty-seven  years,  was  brought  to 
*  Ferguson,  E.  D.:  Phil.  Med.  Jour.,  1899,  iii,  830. 


556  THE    UMBILICUS    AND    ITS    DISEASES. 

my  office  by  Dr.  M.  B.  Hutton,  of  Valley  Falls,  New  York.  He  had  lost  notably  in 
flesh  and  strength,  though  he  was  not  anemic.  He  was  inconvenienced  by  frequent 
urination,  and  complained  of  considerable  pain  in  the  lower  portion  of  the  abdomen. 
Dr.  Hutton  had  satisfied  himself  that  notable  abdominal  enlargement  had  been 
developing  lately,  which  he  ascribed  to  a  tumor  in  the  hypogastric  region.  The 
first  recognition  of  the  tumor  was  about  a  month  earlier,  but  the  first  sense  or  dis- 
comfort was  felt  in  July,  1897,  nearly  a  year  before  the  discovery  of  the  tumor. 

"On  examination  a  flat  tumor  was  found  extending  from  the  pubes  to  about  two 
inches  above  the  umbilicus,  and  from  near  each  anterior  superior  spine  of  the  ilium 
to  its  opposite  fellow.  The  upper  border  was  slightly  irregular  near  the  umbilical 
region,  but  elsewhere  the  contour  was  quite  regular.  The  sense  of  resistance  was 
that  of  a  very  firm,  solid  tumor,  and  at  no  point  could  fluctuation  or  diminished 
hardness  be  found.  There  was,  however,  a  sense  of  nearness  of  the  mass  to  the 
surface,  which  led  me  to  state  that  it  seemed  to  me  to  be  in  the  abdominal  wall,  but 
its  flattened  shape  and  hardness,  together  with  some  irregularity  of  the  upper 
border,  led  me  to  conclude  that  it  was  probabry  a  malignant  disease  of  the  omentum. 
Though  such  a  growth  as  a  primary  trouble  must  be  exceedingly  rare,  the  shape  and 
hardness  led  me  to  that  working  hypothesis,  while  the  freedom  from  evidence  of 
bowel  involvement,  and  the  yet  moderate  constitutional  effects,  led  me  to  advise  an 
exploratory  operation,  the  final  decision  as  to  what  could  and  should  be  done  with 
the  mass  being  left  to  a  consideration  of  the  conditions  found  on  section. 

"I  heard  nothing  further  of  the  patient  until  in  July,  when  his  increasing  size 
and  discomfort  led  him  to  accept  my  somewhat  gloomy,  or  at  least  to  him  unsatis- 
factory, view  of  his  case,  and  he  decided  to  submit  to  an  operation.  Of  course,  the 
absence  of  renal  or  other  contraindication  had  been  established.  The  operation  was 
undertaken  July  26,  1898,  and  the  first  surprise  occurred  when,  on  moving  the  anti- 
septic dressing  after  he  was  under  the  anesthesia,  I  found  the  mass  to  be  then  of  a 
globular  form.  To  this  was  added  a  great  diminution  in  the  sense  of  resistance  and 
a  manifest  fluctuation,  showing  the  cystic  character  of  the  tumor.  This  change  in 
the  tumor  was  undoubtedly  due  to  the  relaxation  produced  by  the  anesthetic  in 
recti  muscles  of  unusual  development.  My  first  impression  now  was  that  I  was 
dealing  with  a  distended  bladder,  for  the  sac  evidently  extended  into  the  pelvis  and 
seemed  more  remote  than  formerly.  Having  satisfied  myself  that  it  was  not  a  dis- 
tended bladder,  I  proceeded  with  the  operation  until  I  came  to  the  wall  of  the  cyst 
just  under  the  deep  fascia  of  the  abdominal  wall.  At  this  juncture  the  nature  of 
the  case  flashed  upon  me,  and  I  was  able  to  state  to  those  present  that  we  were 
dealing  with  a  cyst  of  the  urachus.  This  conclusion  was  strengthened  by  the 
water-like  appearance  of  the  fluid  which  was  removed  by  an  exploring  syringe. 
It  being  apparent  that  the  lower  portion  of  the  cyst  extended  deeply  into  the  pelvis 
and  was  probably  intimately  associated  with  the  bladder-wall,  a  condition  that 
would  explain  the  frequent  urination,  I  exposed  the  wall  of  the  cyst  before  opening 
it,  from  as  near  the  umbilicus  as  the  mergence  of  structures  would  allow,  to  near 
the  pubes.  This  I  did  in  order  to  further  a  plan  which  I  had  quickly  formed  for 
the  management  of  the  case.  In  the  first  place,  I  had  determined  not  to  try  to 
finieleate  the  entire  cyst,  bu1  to  remove  the  posterior  portion  with  the  under- 
lying peritoneum  so  far  as  I  could,  and  allow  the  reclosure  of  the  peritoneum,  dealing 
with  the  remainder  according  to  circumstances.  Such  a  procedure  would  require 
free  access  to  the  deep  portions  of  the  cyst,  hence  my  long  incision.     The  cyst  was 


LARGE    URACHAL    CYSTS.  557 

then  opened  the  entire  extent  of  the  overlying  incision,  and  an  unknown  quantity  of 
water-like  fluid  escaped.  The  quantity,  from  absence  of  convenience  for  collection 
(the  operation  occurring  in  a  private  house),  could  only  be  estimated,  but  it  was  evi- 
dently more  than  two  quarts,  and  probably  less  than  four  quarts. 

"It  was  now  practicable  to  investigate  the  relation  of  the  wall  of  the  cyst  to  con- 
tiguous parts;  it  was  found  to  be  intimately  related  to  the  bladder  over  a  consider- 
able extent  of  the  surface  of  that  organ,  for  it  extended  deeply  into  the  pelvis.  The 
posterior  wall  of  the  cyst  was  free  from  evidence  of  adhesion  or  other  connection 
with  the  abdominal  organs,  and  I  was  about  to  excise  that  portion  of  the  sac  when 
it  occurred  to  me  to  ascertain  whether  the  inner  and  secreting  layer  could  be 
removed,  thereby  securing  a  surface  which  would  unite.  Beginning  at  the  inner  edge 
of  my  incision  in  the  wall  of  the  sac,  and  near  the  lower  end  of  the  opening  of  the 
belly,  I  was  surprised  and  gratified  to  find  that  a  layer  of  tissue,  so  thin  as  to  be  diaph- 
anous in  moderate  light,  and  so  strong  as  to  allow  of  considerable  traction  with- 
out tearing,  could  be  removed  without  much  trouble  and  with  practically  no  hemor- 
rhage. In  that  manner  the  entire  lining  of  the  cyst  was  removed  except  at  the  umbili- 
cal region,  where  quite  a  surface  existed,  in  which  digitations  penetrated  the  abdomi- 
nal wall,  and  a  blending  of  the  tissues  prevented  the  removal  of  the  lining.  This 
surface  seemed  rather  large  for  complete  excision  with  subsequent  easy  closure  of  the 
belly  at  that  point,  hence  it  was  allowed  to  remain  while  attention  was  given  to  the 
denuded  portion  of  the  cyst.  A  single  deep  skin  suture  was  placed  to  divide  the 
unclosed  umbilical  area  from  the  subcutaneous  suturing  below  that  point.  Some 
iodoform  gauze  was  then  placed  in  the  pocket  left  at  the  umbilicus,  where  the  lining 
layer  could  not  be  removed,  and  the  whole  was  sealed  with  a  collodion  seal,  except 
over  the  gauze  packing,  with  the  request  that  it  be  left  for  several  days  unless  indi- 
cations arose  showing  inflammatory  processes. 

"It  had  closed  in  September,  and  the  area  showed  in  December  a  perfectly 
normal  state  of  affairs  aside  from  the  scar  at  the  umbilicus." 

Cyst  of  the  Urachus.*  —  The  patient  from  whom  this  specimen  was 
obtained  was  admitted  to  the  Cook  County  Hospital  February  27,  1895.  He  was  a 
man  fifty-two  years  of  age,  white,  and  single.  He  was  admitted  for  an  illness 
which  had  begun  four  weeks  previously,  with  frequent  micturition  and  pain  in  the 
region  of  the  kidneys.  Examination  revealed  an  enlarged  prostate.  He  had  symp- 
toms of  cystitis  with  retention  of  urine.  Hydronephrosis  was  present,  and  uremia 
ensued.     He  died  on  April  9th. 

Autopsy  Abstract. — "  The  bladder  is  large,  with  markedly  thickened  walls.  Each 
lateral  lobe  of  the  prostate  is  the  size  of  an  English  walnut.  At  the  summit  of  the 
bladder,  and  separated  from  the  bladder  cavity  by  a  thin  membrane,  is  a  cyst,  the 
size  of  an  average  orange.  It  contains  a  thick,  turbid,  viscid,  brownish  fluid.  The 
lining  of  the  cyst  presents  an  irregular  surface,  but  there  are  no  distinct  rugae.  The 
irregularities  of  the  cyst  lining  are  present  on  the  upper  surface  of  the  intervening- 
septum,  between  it  and  the  bladder  cavity.  The  rugae  of  the  bladder  are  continued 
upon  its  inferior  surface.  The  ureters  are  dilated,  as  are  also  the  pelves  of  both  kid- 
neys. Careful  dissection  fails  to  reveal  further  urachus  remains  in  the  abdominal 
wall  or  about  the  navel.  Microscopic  examination  of  the  septum  between  cyst  and 
bladder  cavities  disclosed  the  fact  that  the  muscular  coats  of  the  bladder-wall  were 

*Le  Count,  E.  R.:    Transactions  of  the  Chicago  Pathological  Society,  Dec,  1895,  to  April, 
1897,  ii,  215. 


558 


THE    UMBILICUS    AXD    ITS    DISEASES. 


not  continued  into  the  septum.  This  fact,  taken  in  conjunction  with  the  position 
of  the  cyst  and  the  fact  that  the  peritoneum  of  the  abdominal  wall  was  reflected 
upon  the  back  of  the  cyst,  and  thence  upon  the  back  of  the  bladder,  leaves  no  doubt 
that  the  cyst  represents  the  obliterated  and  dilated  lower  end  of  the  urachus." 

An  Enormous  Cyst  of  the  Urachus.*  — -  The  following  case  is 
cited  on  account  of  some  unusual  features,  and  because  it  should  be  added  to  the 
list  reviewed  by  W.  R.  Weiser  in  a  most  interesting  and  instructive  article  published 
in  the  Annals  of  Surgery  for  October.  1906. 

Miss .  aged  forty.     History  of  slowly  growing  abdominal  tumor,  beginning 

in  the  region  of  the  bladder  and  growing  upward,  with  gradual  onset  of  pressure 
symptoms,  especially  difficult  respiration,  pain,  and  impaired  digestion.  The 
abdomen  was  enormously  distended,  but  not  tender,  nor  did  it  bulge  much  in  the 
flanks.  It  was  rather  firm,  and  was  flat  on  percussion  from  the  pubes  to  the  ensi- 
fonn  cartilage.     Its  appearance  is  well  shown  in  Fig.  239. 


Fig.  239. — The  Abdominal  Contour  in  a  Case  of  Vest  Large  D 


After  T.  L.  Macdonald.) 


"Operation  (October  6.  1907). — Through  the  usual  incision  the  cyst-wall  was 
perforated  and  the  fluid  drawn  off.  Two-thirds  came  away  clear:  the  remainder 
was  turbid,  and.  lastly,  thick,  cheesy  masses  were  wiped  out.  Investigation  of  the 
inside  of  the  sac  disclosed  several  thick,  nodular  masses  which  were  strikingly  car- 
cinomatous in  character.  So  far.  the  peritoneal  cavity  had  not  been  opened,  the 
sac  being  situated  in  front  of  it.  The  task  of  separating  the  cyst-wall  from  the 
peritoneum  and  viscera  was  begun  by  first  stripping  and  cutting  it  from  the  epigas- 
tric region  and  from  beneath  the  ribs,  and  here  the  peritoneal  cavity  was  opened. 
It  was  hoped  that  from  this  point  downward  the  dissection  would  be  less  difficult, 
but  it  was  more  so.  The  anterior  surface  of  the  peritoneum  seemed  to  be  fused  with 
the  sac,  and  the  posterior  with  the  viscera  generally:  and  the  character  of  the 
adhesions  was  the  most  dense  ever  encountered  by  the  writer.  These  were  followed 
deeply  into  the  pelvis,  in  all  directions,  and  freed:    and  finally  the  firm,  fibrous 

*  Macdonald,  T.  L.:  Ann.  Surg:..  July-December,  1907,  xlvi.  230. 


LARGE    URACHAL    CYSTS. 


559 


attachment  to  the  bladder  was  severed  and  the  sac  removed.  The  appendix,  six 
inches  in  length,  bright  red,  and  surrounded  by  adhesions,  was  also  removed.  The 
abdomen  now  presented  a  most  unusual  sight.  With  the  exception  of  the  anterior 
surface  of  the  stomach,  not  a  vestige  of  normal  peritoneum  was  visible.  All  the 
abdominal  contents,  including  tubes,  ovaries,  uterus,  and  bladder,  could  be  seen 
outlined  through  the  thin,  raw  film  of  peritoneum  to  which  they  were  firmly 
attached.  The  abdominal  cavity  was  filled  with  normal  salt  solution  and  closed 
with  three  layers  of  buried  absorbable  sutures  without  drainage. 

"Fig.  240  shows  some  of  the  nodular  masses.  There  are  others  on  the  oppo- 
site side.  These  were  on  the  inner  surface  of  the  sac,  which  was  photographed  in 
this  way.  The  cyst  was  turned  inside  out,  and  through  the  incision,  which  had 
served  for  the  evacuation  of  the  contents,  a  large,  thin,  collapsed  rubber  punching 
bag  was  thrust,  then  inflated,  thus  distending  the  sac  for  photographic  purposes. 

"The  report  of  our  hospital  pathologist,  Dr.  Birdsall,  shows  the  cyst-wall  to  be 
fibrous,  and  the  nodular  masses,  which,  dur- 
ing operation  we  feared  were  carcinomatous, 
were  papillomata.  Of  course,  in  a  cyst  of 
this  size,  which  had  been  growing  presum- 
ably for  forty  years,  and  subjected  to  the 
ever-increasing  pressure  of  the  accumulating 
fluid,  we  could  not  expect  to  find  the  normal 
histologic  features  of  the  urachus.  Natur- 
ally, all  except  the  fibrous  structures  would 
disappear  by  pressure  absorption ;  even  bone 
has  been  known  to  do  the  same. 

"Postoperative  Course. — The  patient's 
condition  was  critical  for  the  two  following 
days,  active  stimulation  and  intravenous 
saline  infusion  being  demanded.  The  wound 
healed  by  primary  union.  The  bowels  were 
loose.  The  temperature  ranged  from  101°  to 
102°  F.  Daily  palpation  of  the  abdomen  re- 
vealed fluctuation,  and  the  percussion-note 

was  flat,  showing  that  the  salt  solution  was  not  being  absorbed.  On  the  seventh 
day  a  chill  occurred,  followed  by  a  rise  in  temperature  to  104°  F.  Assuming  that  the 
unabsorbed  solution  had  become  infected  through  the  raw  surface  of  the  intestines, 
the  lower  end  of  the  now  healed  wound  was  cocainized  and  cut  through,  allowing 
the  escape  of  quarts  of  the  salt  solution,  which  had  become  purulent,  and  which  pre- 
sented the  colon  bacillus  characteristics.  This  was  followed  by  prompt  improvement. 
Drainage  and  irrigation  were  continued  for  a  week,  after  which  the  wound  closed 
and  convalescence  and  return  to  health  were  satisfactory. 

"Comments. — The  density  of  the  adhesions  cannot  be  appreciated  unless  en- 
countered. It  is  true,  incision,  evacuation,  and  drainage  would  probably  have 
been  successful  after  a  long  period  of  waiting  for  the  cavity  to  undergo  obliteration. 
The  assumption,  however,  that  portions  of  the  sac  had  become  carcinomatous 
made  extirpation  seem  imperative. 

"Extirpation  is  evidently  not  commonly  resorted  to.     Among  the  86  cases  re- 


Fig.  240. — A  Urachal  Cyst  Turned  Inside  Oct 
and  Showing  Papillary  Masses,  Particu- 
larly in  the  Lower  Part  of  the  Picture. 
(After  T.  L.  Macdonald.) 


560  THE    UMBILICUS    AXD    ITS    DISEASES. 

viewed  by  Dr.  Weisef,  only  eight  were  extirpated.     Xone  of  these  was  said  to  be 
large,  and  with  one  or  more  the  history  and  result  were  lacking." 

Dilated  Urachus  Treated  by  Incision  and  Drainage.* 
-The  patient.  W.  J.  P..  was  a  man  aged  fifty-four  who  consulted  Dr.  Pratt  on 
June  8.  1889.  complaining  of  pain  and  distention  in  the  abdomen  and  increasing 
general  weakness.  He  had  been  quite  well  until  the  previous  November,  when  he 
complained  of  pain  in  the  lower  part  of  the  abdomen.  He  remained  in  bed  for  three 
weeks  and  in  the  house  for  four  months.  He  could  not  account  for  the  onset  of  the 
trouble  in  any  way.  There  had  been  no  blow,  no  lifting  of  heavy  weights,  nor 
straining  of  any  kind.  His  occupation  was  that  of  a  store-keeper  and  clerk  near 
Xew  York,  where  he  had  lived  for  many  years.  He  had  had  a  gonorrheal  infection 
when  twenty-one.  but  had  never  had  symptoms  of  syphilis.  He  had  led  a  very 
intemperate  life  until  seven  or  eight  years  previously.  Since  then  he  had  been  a 
moderate  drinker.  On  examination  the  abdomen  was  found  to  be  much  distended 
in  the  lower  half  and  in  front :  the  distended  area  was  dull  on  percussion  and  reached 
as  high  as  three  fmgerbreadths  above  the  umbilicus.  The  pain  extended  as  far  as 
the  pubes.  laterally,  on  either  side,  as  far  as  vertical  lines  drawn  through  the  anterior 
superior  iliac  spines.  He  had  no  trouble  with  micturition  or  defecation.  The  urine 
appeared  to  be  normal.  The  prostate  was  not  enlarged,  but  there  was  a  fulness  of 
the  left  side  of  the  pelvis. 

On  June  15.  1889.  the  tumor  was  aspirated  and  about  one  dram  of  a  gummy, 
semitransparent  fluid,  which  blocked  the  tube  was  withdrawn.  It  contained  only 
a  trace  of  albumin,  but  a  large  quantity  of  mucin,  as  shown  by  the  precipitate  it  gave 
with  acetic  acid.     Microscopically  it  showed  many  leukocytes. 

On  July  9th  Mr.  Bond  made  a  four-inch  median  incision  midway  between  the 
umbilicus  and  the  pubes.  After  division  of  the  linea  alba  a  very  thick  membrane 
was  reached,  resembling  a  peritoneum  much  thickened  by  tubercular  peritonitis.  It 
proved,  however,  to  be  the  outer  wall  of  the  cyst.  It  was  divided,  and  a  very  large 
quantity  of  a  ropy,  gummy,  semisolid  material  came  away,  of  which  over  a  gallon 
was  measured.  This  had  the  appearance  and  consistence  of  semi-decolorized  fibrin, 
was  partly  squeezed  and  partly  drawn  out  in  stringy  layers.  A  considerable 
quantity  was  left  in  the  cavity,  as  any  attempt  to  sponge  it  off  the  inner  surface  of 
the  cyst-wall  left  a  red.  raw  surface  which  bled  freely.  On  exploration  of  the  cavity 
with  the  hand  and  arm  it  was  found  to  extend  upward  to  and  beneath  the  liver  and 
downward  into  the  pelvis.  The  intestines  could  be  made  out  behind  and  at  the 
sides  of  the  cyst,  though  shut  off  and  separated  from  it.  The  peritoneal  cavity  was 
not  opened.  A  Keith  drainage-tube  was  placed  in  the  wound,  and  reached  to  the 
floor  of  the  pelvis.     The  rest  of  the  incision  was  closed. 

Chemical  examination  showed  that  there  was  only  a  trace  of  albumin,  that  the 
fluid  was  practically  mucus  and  fibrin,  with  a  large  predominance  of  the  former. 
Microscopic  examination  showed  mucus-corpuscles  and  blood. 

The  cyst-walls  shrank,  and  the  patient  gradually  improved.  In  December 
1889,  on  his  departure  for  America,  he  seemed  to  be  in  good  health,  could  walk  nine 
miles  at  a  stretch,  and  his  appetite  was  excellent.  There  still  remained,  however, 
an  irregular  shaped  cavity  with  thickened  walls  capable  of  holding  half  a  pint  of 
fluid.  Mucoid  material  was  secreted  daily.  The  discharge,  however,  was  not 
fetid  and  did  not  seem  to  in  any  way  depress  his  health.  In  a  letter  dated  February 
*  Pratt.  R..  and  Bond.  C.  J.:  The  Lancet.  1890,  i,  898. 


LARGE    URACHAL    CYSTS.  561 

27,  1890,  the  patient  said  that  the  wound  was  still  kept  open  by  a  glass  tube,  and 
that  there  was  a  discharge  of  clear,  watery  fluid,  with  very  little  of  the  jelly-like 
material.     The  man  was  in  excellent  health  and  was  working  thirteen  hours  a  day. 

A  True  Urachal  Cyst.  —  Von  Recklinghausen*  demonstrated  a  cyst, 
about  the  size  of  a  walnut,  which  had  been  removed  from  a  man  thirty  years  of  age. 
The  cyst  varied  from  1  to  3  cm.  in  diameter,  and  contained  tenacious,  colorless 
mucus.  It  was  situated  directly  at  the  top  of  the  bladder,  with  which  it  was  inti- 
mately connected.  It  lay  in  the  median  line  in  the  subperitoneal  adipose  tissue,  and 
was  completely  cut  off  from  the  bladder.  It  was  polycystic.  There  was  a  main 
cavity  with  many  bays  running  off  from  it,  and  in  addition  to  this  there  was  a  small 
cystic  mass  which  was  attached  to  the  bladder,  and  which  contained  a  labyrinth  of 
microscopic  spaces  looking  like  gland  loops,  or,  at  any  rate,  like  dilated  crypts.  The 
dense  connective-tissue  walls  were  nearly  everywhere  covered  over  with  bundles  of 
smooth  muscle-fibers.  The  epithelium  was  several  (or  usually  two)  layers  in  thick- 
ness, and  was  definitely  squamous  in  type.  Here  and  there  in  the  crypts  were 
abundant  numbers  of  goblet-cells.  On  account  of  the  presence  of  goblet-cells  it  was 
necessary  to  consider  the  possibility  of  an  enterocystoma;  in  other  words,  a  deriva- 
tive from  the  omphalomesenteric  duct.  But  von  Recklinghausen  said  that  this 
could  be  excluded,  because  the  tumor  was  entirely  extraperitoneal  and  because  it 
was  in  no  way  connected  with  the  peritoneum. 

Cyst  of  the  Urachus.  —  Reedf  cites  a  case  (his  Fig.  321)  in  which  the 
sac  had  extended  from  near  the  ensif orm  cartilage  to  the  pubes  and  forced  the  viscera 
from  their  normal  positions.  The  cyst  was  enucleated  without  any  opening  into  the 
peritoneal  cavity.  He  gives  a  schematic  picture  of  the  condition.  Microscopic 
details  are  lacking. 

Probably  a  Urachal  Cyst.t  —  This  case  was  also  reported  by  Freer. 
A  divinity  student  had  from  infancy  been  remarkable  for  his  large  abdomen, 
which  had  made  him  an  object  of  ridicule  to  his  companions.  Thinking  adipose 
tissue  to  be  the  cause,  he  had  tried  to  reduce  it  by  fasting,  but  without  avail.  It 
caused  him  no  trouble  until  his  twenty-fourth  year,  when  a  marked  increase  in  size 
took  place.  This  seriously  impeded  his  respiration  and  led  to  an  examination,  which 
revealed  fluctuation  in  and  around  the  umbilical  region.  The  dyspnea  having 
increased  to  such  a  degree  that  relief  became  imperative,  a  puncture  was  made  and 
a  considerable. quantity  of  reddish-yellow  fluid  escaped.  The  procedure  was  fol- 
lowed by  vomiting  and  intense  abdominal  pain.  The  puncture  afforded  him  some 
relief,  and  with  the  exception  of  occasional  fainting  spells,  his  health  remained  good 
for  a  period  of  two  years,  after  which  his  abdomen  again  commenced  to  increase  in 
size,  the  dyspnea  returned,  and  his  general  appearance  became  cachectic.  He  again 
entered  the  hospital  and  six  liters  of  bloody  fluid  were  withdrawn.  The  operation 
was  repeated  three  times  during  the  ensuing  nine  months — the  remainder  of  his  life. 
The  amounts  of  fluid  were  18^,  17,  and  6  liters  respectively.  At  his  death  he 
weighed  about  192  pounds.  At  autopsy  the  contents  of  the  cyst  were  found  to 
amount  to  50  liters,  which  weighed  about  100  pounds.     The  cyst  fluid  contained 

*Von  Recklinghausen:     Eine  richtige  TJrachuscyste.     Deutsche  med.  Wochenschr.,   1902, 
xxviii,  Vereinsbeilage,  266. 

t  Reed,  Charles  A.  L.:  A  Text-Book  of  Gynecology,  1901,  805. 

i  Rippmann,  G. :  Eine  serose  Cyste  in  der  Bauchhohle,  mit  einem  Inhalt  von  50  Liter  Fliis- 
sigkeit.     Deutsche  Klinik,  1870,  xxii,  267. 
37 


562  THE    UMBILICUS    AND    ITS    DISEASES. 

cholesterin  crystals,  flat  epithelium,  and  fat-droplets.  A  minute  examination  of  the 
cyst-wall  showed  it  to  consist  of  three  layers,  the  external  being  a  serous  coat.  This 
rested  on  a  layer  composed  of  elastic  and  fibrous  tissue,  and  the  interior  was  lined 
with  pavement  epithelium.  The  bladder  contained  a  little  yellowish  urine.  It 
was  contracted,  and  its  lining  mucous  membrane  was  pale.  The  urachus  was  found 
closed  at  the  bladder  end.  In  its  course  toward  the  umbilicus  below  the  commence- 
ment of  the  large  cyst,  a  small  cyst  was  situated  near  the  umbilicus.  The  fibrous 
tissue  passed  into  the  subperitoneal  coat  of  the  larger  cyst,  which  occupied  almost 
the  whole  abdominal  cavity,  but  the  cyst  was  absolutely  independent  of  the  ab- 
dominal cavity  and  the  abdominal  organs  were  normal. 

Probably  a  Urachal  Cyst.  —  Schaad's*  patient  was  a  married 
woman  thirty-two  years  of  age.  Nothing  was  known  about  the  condition  of  the 
umbilicus  at  birth.  She  had  had  two  normal  labors.  At  the  last  labor  a  tumor  had 
been  noted  below  the  umbilicus.  The  patient  was  supposed  to  have  had  a  severe 
inflammation  of  the  bowels  seven  years  before.  Several  fingerbreadths  below  the 
umbilicus  could  be  felt  an  elastic  tumor  the  size  of  a  child's  head.  It  could  be 
sharply  outlined  and  pushed  in  all  directions. 

A  cyst  the  size  of  a  five-franc  piece  was  found  situated  about  two  fingerbreadths 
below  the  umbilicus,  and  attached  to  the  abdominal  wall  in  the  mid-line.  It  was 
separated  from  the  peritoneum  and  drawn  out  of  the  abdomen.  The  omentum  was 
tied  off;  the  cyst  was  found  adherent  to  the  appendix.  The  left  ovary  was  hard 
and  atrophic;  the  right  ovary  was  normal.     The  patient  recovered. 

The  cyst  was  oval  in  form,  and  measured  7.5  x  6  x  4.5  cm.  The  walls  varied 
from  2  to  4  mm.  in  thickness.  The  outer  surface  was  fairly  smooth,  except  where  it 
was  adherent.  The  inner  surface  resembled  mucosa  and  was  light  yellow  in  color, 
with  dark  spots.  On  the  right  side  of  the  cyst  was  a  secondary  cyst  opening  into  the 
larger  one.  The  opening  was  the  size  of  a  pin-head.  The  inner  surface  of  this 
second  cyst  was  smooth  and  yellow;  its  walls  were  1  mm.  thick.  The  large  cyst 
contained  about  200  c.c.  of  a  chocolate-colored,  cloudy,  tenacious  fluid,  showing 
much  cholesterin,  detritus,  fat-droplets,  etc.  The  contents  of  the  small  cyst  were 
similar  in  character,  but  thicker.  The  wall  of  the  large  cyst  consisted  of  connective 
tissue  and  large  quantities  of  smooth  muscle  arranged  in  bundles.  These  ran  in  all 
directions.  The  inner  surface  was  lined  with  high  cylindric  epithelium;  there  were 
also  glands  opening  upon  the  surface.  In  places  the  epithelium  and  glands  were 
absent.  The  small  cyst  was  lined  with  granulation  tissue,  in  which  were  encoun- 
tered giant-cells,  some  containing  as  many  as  20  or  30  nuclei,  arranged  at  the  margin 
or  irregularly  scattered  or  in  the  center.  [These  are  suggestive  of  foreign-body 
giant-cells.]  Schaad  felt  sure  that  he  was  dealing  with  an  omphalomesenteric 
duct,  a  portion  of  which  had  remained  open,  with  a  resulting  retention  cyst. 
[From  the  cases  followed  in  the  literature  the  case  strongly  suggests  a  urachal  cyst. 
The  question,  however,  is  an  open  one. — T.  S.  C] 

A  C  y  s  t  i  c  Urachus.  —  Scholzf  reports  the  case  of  a  sixteen-year-old  girl 
who  complained  of  difficulty  in  micturition  and  a  painful  tumor  in  the  abdomen. 
The  abdomen  was  prominent,  the  largest  measurement  being  between  the  umbilicus 
and  symphysis.     The  tumor  was  very  painful.     On  both  sides  there  was  tympany. 

*  Schaad,  T.:  Ueber  die  Exstirpation  einer  Cyste  des  Dotterganges.  Correspondenzbl. 
f.  Schweizer  Aerate,  1886,  xvi,  345. 

fScholz:  Wien.  med.  Wbchenschr.,  187S,  xxviii,  1327. 


LARGE    URACHAL    CYSTS.  563 

After  a  time  an  opening,  about  the  size  of  a  hair,  developed  at  the  umbilicus,  and 
fluid  escaped  from  it.  The  opening  was  dilated  and  about  300  c.c.  of  colorless, 
transparent,  thick,  tenacious  fluid  escaped,  and  finally  a  thick  yellow  pus.  The 
wound  closed  in  the  course  of  two  months. 

A  Large  Urachal  Cyst.*  —  Case  1. — "This  case  was  sent  to  me  by 
Dr.  Lamb,  of  Albrighton.  She  had  complained  of  abdominal  pain  and  tenderness, 
and  in  October,  1880,  she  began  to  suffer  from  somewhat  serious  symptoms,  more 
particularly  frequent  vomiting  and  disinclination  to  take  solid  food.  Some  swelling 
in  the  lower  part  of  the  abdomen  was  noticed  about  the  same  time,  this  being  then 
regarded  as  ascitic.  The  symptoms  slowly  increased  in  severity  until  February  11, 
1881,  when  a  consultation  was  held  between  Drs.  Lamb,  Heslop,  and  Saundby.  As 
a  result  of  this  consultation  she  was  tapped,  and  10  pints  of  fluid  were  removed, 
although  this  was  by  no  means  the  amount  of  fluid  in  the  cavity,  because  large 
masses  of  flocculi  obstructed  the  tube  of  the  trocar  and  prevented  the  complete 
emptying  of  the  cyst.  Some  of  this  fluid  was  submitted  to  me  for  an  opinion,  and 
from  the  fact  that  it  was  brown  and  thick  and  gave  an  abundant  flaky  yellow  de- 
posit, which  consisted  chiefly  of  pus,  I  unhesitatingly  gave  the  opinion  that  it  was 
not  ascitic,  but  a  fluid  that  must  have  been  contained  in  some  cyst  cavit3T,  probably 
a  cyst  of  the  parovarium.  I  saw  her  on  February  13th,  when  we  found  that  the 
abdomen  was  quite  as  much  distended  as  before  the  tapping.  I  therefore  pro- 
posed an  exploratory  incision  for  the  removal  of  the  tumor,  if  it  were  possible  to 
remove  it,  although  the  extremely  exhausted  condition  of  the  patient  gave  no 
very  great  prospect  of  success.  It  was  perfectly  clear,  however,  that  if  let  alone 
nothing  but  death  could  be  the  result,  and  therefore  an  operation  was  accepted  by 
her  attendants  and  relatives. 

"  I  opened  the  abdomen  at  the  usual  site,  and  after  cutting  through  all  the  layers 
except  the  peritoneum  I  came  upon  the  cyst-wall.  I  opened  the  cyst  and  removed 
about  30  pints  of  fluid,  exactly  the  same  as  that  which  had  been  removed  at  the 
tapping;  and  mixed  up  with  it  I  found  large  masses  of  the  fibrinous  deposit,  which 
accounted  for  the  failure  of  the  tapping  to  remove  the  whole  of  the  fluid.  I  then 
proceeded  to  remove  the  enormous  cyst,  which  was  uniformly  attached  to  the 
parietal  wall  on  its  outer  aspect,  and  to  the  outer  surface  of  the  thickened  peritoneum 
on  its  posterior  aspect.  The  cyst  did  not  dip  into  the  pelvis  at  all,  and  the  anterior 
parietal  peritoneum  did  not  reach  the  wall  lower  than  the  ensiform  cartilage.  The 
intestines  and  the  pelvic  organs  could  be  felt  through  the  anterior  peritoneal  fold, 
non-adherent,  and,  as  far  as  could  be  determined,  perfectly  healthy.  The  cyst  lay, 
therefore,  entirely  between  the  transversalis  fascia  on  the  outer  side  and  the  parietal 
peritoneum  on  the  inner,  the  peritoneal  cavity  having  been  nowhere  opened  during 
the  severe  and  protracted  operation.  The  cyst  was  removed  in  its  entirety,  and  its 
inner  surface  consisted  of  broken-down  mucoid  epithelium,  infiltrated  everywhere 
with  pus,  lying  upon  the  basement  membrane,  wmich  consisted  almost  entirely  of 
muscular  fibers. 

"The  conclusion  concerning  the  nature  of  this  cyst,  at  which  I  have  arrived,  is 
that  it  was  developed  from  the  urachus,  a  part  of  which  had  been  occluded  at  both 
ends,  but  during  the  developmental  changes  of  embryonic  and  infantile  existence  had 
not  become  obliterated.  I  entirely  fail  to  see  any  other  possible  origin  for  it,  and, 
if  my  explanation  be  correct,  it  is  very  marvelous  that  this  structure  should  have  re- 

*  Tait,  Lawson:  Twelve  Cases  of  Extraperitoneal  Cysts.     Brit.  Gyn.  Jour.,  1886-87,  ii,  32S. 


564  THE    UMBILICUS    AND    ITS    DISEASES. 

mained  quiescent  for  fifty-six  years  and  then  should  suddenly  undergo  an  inflamma- 
tory change  which  developed  it  into  this  enormous  cyst.  The  patient  went  on  very 
well  for  three  days,  and  then  rapidly  sank  from  exhaustion.  No  postmortem  ex- 
amination was  allowed,  and  therefore  I  can  shed  no  further  light  upon  it;  and,  as 
far  as  I  know,  the  observation  is  unique,  although  it  is  perfectly  well  known,  as  I 
myself  have  repeatedly  had  occasion  to  observe,  that  small  cysts  of  the  urachus  are 
opened  in  abdominal  section.  I  do  not  know  that  any  such  cyst  has  previously 
been  met  with  sufficiently  large  to  be  of  pathologic  importance.  It  was  noted  and 
published  at  the  time  that  the  basement  membrane  of  this  cyst  consisted  almost 
entirely  of  muscular  fiber,  an  observation  which  is  absolutely  concurrent  with  the 
examination  of  the  cyst  in  Case  X,  made  by  Mr.  Bland-Sutton." 

Probably  a  Large  Urachal  Cyst.*  —  Case  XI. — -"This  case 
was  sent  to  me  by  Dr.  T.  S.  Bourne,  of  Kenilworth,  as  a  case  of  acute  inflammatory 
disease  of  the  abdomen,  of  which  he  said:  "I  find  it  impossible  to  make  an  exact  di- 
agnosis." When  I  saw  her  I  found  her  with  a  high  pulse  and  temperature,  and  ab- 
domen distended  with  a  large  quantity  of  free  fluid.  My  opinion,  expressed  at  the 
time,  was  that  it  was  a  case  of  tubercular  peritonitis.  I  made  the  usual  section,  and 
found  it  another  of  these  cases  of  congenital  cysts  belonging  to  the  category  of  the 
cases  already  described  in  numbers  IV,  V,  VI,  VII,  VIII,  IX,  and  X.  I  removed  a 
small  piece  of  the  cyst-wall  for  examination,  and  the  reports  of  the  microscopic  exam- 
ination by  Dr.  Arthur  Johnstone  and  Mr.  J.  Bland-Sutton  of  Cases  X  and  XI  are 
annexed.  I  used  the  circular  drainage  method,  and  the  patient  has  completely 
recovered.     The  following  is  Mr.  Bland-Sutton's  report: 

"Sections  of  the  cyst-wall  exhibited  under  the  microscope  a  mixture  of  fibrous 
and  non-striated  muscle  tissue  arranged  in  fasciculi,  closely  corresponding  to  the 
disposition  of  the  bundles  of  tissue  which  make  up  the  walls  of  the  urinary  bladder- 
Scattered  throughout  the  whole  thickness  of  the  sections  were  small  calcareous 
nodules.  It  was  difficult  to  make  out  any  definite  epithelial  investment  to  the 
sections,  but  on  scraping  the  smooth  surface  of  the  specimen  with  a  cover-glass,  the 
field  of  the  microscope  became  crowded  with  flattened,  rounded,  and  pyriform  cells, 
similar  to  those  found  lining  the  interior  of  the  urinary  bladder,  only  very  much 
smaller. 

"As  the  urachus  is  lined  with  epithelium  agreeing  in  shape,  and  continuous 
with  that  found  in  the  interior  of  the  bladder,  the  evidence  that  these  cysts  are 
allantoic  seems  to  me  to  be  complete  (J.  Blancl-Sutton)." 

[Tait  cites  a  considerable  amount  of  literature  and  discusses  other  cases  at 
length.  It  is  very  difficult  to  tell  in  the  majority  of  these  cases  whether  he  was 
right  in  his  assumption  or  not.  His  entire  paper,  however,  is  a  very  interesting 
one.— T.  S.  C] 

A  Urachal  Cyst.  —  Wolff  |  reports  two  cases  which  came  under  his 
observation  in  the  clinic  in  Marburg  in  1872,  and  which,  according  to  his  view,  were 
urachal  cysts.     I  shall  here  report  only  Wolff's  Case  I. 

Mrs.  K.,  aged  thirty-one,  was  always  healthy  in  childhood.  Two  years  before 
her  admission  she  noticed  a  tumor  in  the  left  side  of  the  lower  abdomen.  This  grad- 
ually increased.     In  March,  1872,  there  was  a  pregnancy  which  terminated  nor- 

*  Tait,  Lawson:  Loc.  cit.,  Case  xi. 

f  Wolff,  C.  C:   Beitrag  zur  Lehre  von  den  Urachuscysten.     Inaug.  Diss.,  Marburg,  1873. 


LARGE    URACHAL    CYSTS.  565 

mally,  but  was  followed  by  an  acute  fever,  with  severe  pain  in  the  left  part  of  the 
abdomen.  The  abdomen  suddenly  reached  enormous  proportions  in  a  few  days. 
The  patient  was  treated  by  her  physician  for  peritonitis.  Convalescence  was  slow, 
but  the  patient  again  became  quite  strong.  On  palpation  of  the  abdomen,  a  tense, 
elastic,  fluctuant,  rounded  tumor  could  be  felt.  This  filled  the  entire  left  side  of  the 
lower  abdomen,  and  extended  over  to  the  right  a  handbreadth  beyond  the  linea  alba. 
Upward  it  reached  beyond  the  umbilicus.  The  tumor  could  not  be  pushed  from 
side  to  side.  It  had  a  smooth  surface,  and  apparently  consisted  of  one  mass.  A 
median  incision  was  made,  but  the  peritoneum  did  not  become  visible.  After 
careful  dissection  the  cyst  was  opened  and  yellowish,  serum-like  fluid  escaped.  The 
patient  was  laid  on  her  side  and  the  contents  of  the  cyst  gradually  flowed  out.  After 
5  liters  of  fluid  had  been  removed  in  this  way,  the  tumor  was  gradually  loosened. 
The  peritoneum  was  thickened,  evidently  as  a  result  of  inflammation.  In  the  inner 
part  of  the  cyst  were  large,  lumpy  coagula  of  fibrin.  The  connection  of  the  cyst  with 
the  peritoneum  was  in  part  firm  and  in  part  very  loose.  The  tumor  was  shelled  out 
without  difficulty.  It  was  possible  to  do  the  operation  almo.st  entirely  extraperi- 
toneally;  only  at  one  point  was  the  peritoneum  opened  for  a  distance  of  1  cm.  This 
was  closed  with  silk.     The  patient  made  a  good  recovery. 

The  cyst  was  egg-shaped.  Its  largest  circumference  was  63  cm.  When  flat- 
tened out  it  was  31  cm.  in  breadth.  The  cyst-walls  varied  from  1  to  3  or  4  mm.  in 
thickness.  The  outer  surface  was  rough,  with  numerous  string-like  processes  which 
indicated  where  the  adhesions  to  the  peritoneum  had  been  cut.  It  had  a  poor 
blood-supply.  The  cyst-wall  had  a  tough  consistence.  The  interior  of  the  cyst  was 
smooth,  like  a  serous  wall.  It  had  over  its  surface  fibrinous  deposits.  According 
to  Lieberkuhn,  who  made  the  histologic  examination,  the  cyst-wall  consisted  of 
fine  connective  tissue  with  fibers  running  in  various  directions;  here  and  there  were 
non-striated  muscle-fibers.  A  definite  epithelium  was  not  detected  on  the  inner 
surface.     The  fluid  consisted  of  large  granular  masses  of  detritus  and  pus-cells. 


LITERATURE  CONSULTED  ON  LARGE  NON-INFECTED  URACHAL  CYSTS. 
Atlee,  W.  L.:   Ovarian  Tumors,  Lippincott,  Philadelphia,  1873,  50. 
Baldwin:  Large  Cyst  of  the  Urachus.     Surg.,  Gyn.,  and  Obst.,  1912,  xiv,  636. 
Bantock:  See  Tait's  article. 

Bryant,  T.:  Discussion  on  Doran's  paper,  Brit.  Med.  Jour.,  1898,  i,  1390. 
Carroll,  J.  W.:  Cystic  Urachus.     Buffalo  Med.  Jour.,  1895-96,  xxxv,  869. 
Cotte  et  Delore:  Gros  kyste  de  l'ouraque.     Lyon  med.,  1905,  cv,  373. 
Doran,  A.  H.  G.:    Urachal  Cyst  Simulating  Appendicular  Abscess;    Arrested  Development  of 

Genital  Tract;    with  Notes  on  Recently  Reported  Cases  of  Urachal  Cysts.     The  Lancet, 

1909,  i,  1304. 
Dossekker:   Klin.  Beitr.  z.  Lehre  von  den  Urachuscysten.     Beitrage  z.  klin.  Chir.,  1893,  x,  102. 
Douglas,  R.:    Cysts  of  the  Urachus.     Trans.  Amer.  Assoc,  of  Obstet.  and  Gynecologists,  1897, 

x,  177. 
Ferguson,  E.  D.:  Cysts  of  the  Urachus.     Phila.  Med.  Jour.,  1899,  hi,  830. 
Ill,  E.  J.:   Tumors  of  the  Urachus.     Trans.  Amer.  Assoc,  of  Obstet.  and  Gynecologists,  1892,  v, 

238.— Amer.  Jour.  Obstr.,  1897,  xxxvi,  568. 
Le  Count,  E.  R. :  Cyst  of  Urachus.     Trans.  Chicago  Path.  Soc,  Dec,  1895,  to  April,  1897,  ii,  215. 
Macdonald,  T.  L.:   An  Enormous  Cyst  of  the  Urachus.     Annals  of  Surg.,  July-December,  1907, 

xlvi,  230. 
Pratt  and  Bond:    Dilated  Urachus  Treated  by  Incision  and   Drainage.     The  Lancet,  1890,  i, 


566  THE    UMBILICUS    AND    ITS    DISEASES. 

Von  Recklinghausen:    Eine  richtige  Urachuscyste.     Deutsche  med.  Wochenschr.,  1902,  xxviii, 

Vereinsbeilage,  266. 
Reed,  C.  A.  L. :  Cyst  of  the  Urachus.     A  Text-Book  of  Gynecology,  1901,  805. 
Rippmann,  G.:  Eine  serose  Cyste  in  der  Bauchhohle,  mit  einem  Inhalt  von  50  Liter  Fliissigkeit. 

Deutsche  Klinik,  1870,  xxii,  267. 
Schaad,  T.:  Ueber  die  Exstirpation  einer  Cyste  des  Dotterganges.     Correspondenzbl.  f.  Schweizer 

Aerzte,  1S86,  xvi,  345. 
Scholz:    Cystis  urachi.     Bericht  des  k.  k.  Allg.  Krankenhauses,  Wien,  1877  (quoted  by  Wutz) . 
Tait,  L.:  Twelve  Cases  of  Extraperitoneal  Cysts.     Brit.  Gyn.  Jour.,  1886-87,  ii,  328. 
Weiser,  W.  R.:  Cysts  of  the  Urachus.     Annals  of  Surg.,  1908,  xliv,  529. 
Wolff,  C.  G:   Beitrag  zur  Lehre  von  den  Urachuscysten.     Inaug.  Diss.,  Marburg,  1873. 
Wutz,  J.  B.:  Ueber  Urachus  und  Urachuscysten.     Virchows  Arch.,  1883,  xcii,  387. 


CHAPTER  XXXIII. 

ABSCESSES    IN    THE    ANTERIOR  ABDOMINAL  WALL    BETWEEN   THE 

UMBILICUS  AND  SYMPHYSIS  DUE  TO  INFECTION  OF  URACHAL 

REMAINS  OR  OF  URACHAL  CYSTS. 

Report  of  a  personal  observation. 
Clinical  course. 
Treatment. 

Cases  of  abscess  of  the  abdominal  wall  due  to  infection  of  remains  of  the  urachus,  and  not  com- 
municating with  the  bladder. 

My  attention  was  particularly  drawn  to  this  group  of  cases  in  1910  when  Dr. 
L.  Gibbons  Smart,  of  Lutherville,  Md.,  askecl  me  to  see  a  boy,  aged  fifteen,  who  was 
complaining  of  a  hard  mass  extending  from  the  symphysis  to  the  umbilicus  in  the 
mid-line.     There  was  no  history  of  abdominal  injury. 

Seven  weeks  before,  the  patient  had  begun  to  suffer  with  severe  pain  in  the 
lower  abdomen.  On  making  an  examination  he  had  noted  that  it  was  very  hard  to 
the  touch,  but  not  tender.  His  pain  had  been  constant  during  one  day,  and  then 
had  disappeared,  only  to  recur  every  few  days  and  last  a  day  or  two  at  a  time. 
Sometimes  the  pain  in  the  mid-line  had  disappeared;  on  other  occasions  it  had  been 
referred  to  the  right  or  left  side.  He  did  not  remember  having  had  chills  or  fever 
until  two  weeks  before  entering  the  hospital,  when  he  had  had  a  chill,  followed  by  an 
elevation  of  temperature.     After  this  there  had  been  several  chills. 

He  had  had  no  increased  pain  when  voiding  and  had  never  passed  any  urine 
from  the  umbilicus,  nor  had  he  any  umbilical  discharge.  He  said  he  remembered 
having  had  a  few  night-sweats. 

His  appetite  for  the  last  eight  weeks  had  been  very  poor,  following  a  period  of 
several  months  when  he  seemed  unable  to  satisfy  his  craving  for  food. 

The  patient  was  a  well-developed  and  healthy  looking  youth.  He  said  that  at 
the  time  he  first  noticed  the  condition  his  abdomen  was  just  as  hard  as  it  was  on  the 
day  that  he  entered  the  hospital,  seven  weeks  later.  His  bowels  were  usually 
constipated ;  his  urine  was  normal. 

Operation. — Church  Home  and  Infirmary,  June  11,  1910.  Under  anesthesia 
it  was  noted  that  the  umbilicus  was  more  prominent  than  usual,  and  that  it  welled 
out  on  both  sides  (Fig.  241) .  The  hardness  in  the  abdominal  wall  also  became  much 
more  evident  when  the  patient  was  asleep.  I  made  an  incision  commencing  just 
below  the  umbilicus  and  extending  to  the  symphysis.  After  separating  the  recti 
we  found  that  the  tumor  lay  extraperitoneally.  It  was  exceedingly  hard,  and 
almost  as  dense  as  cartilage.  An  incision  having  been  carefully  made  through  this 
hard  tissue,  we  encountered  a  sac,  somewhat  irregular  in  form,  and  filled  with 
brownish,  grumous  contents  amounting  to  about  50  c.c.  The  cavity  was  carefully 
scraped  out.  A  portion  of  the  thickened  wall  was  removed  for  examination,  and 
the  cavity  packed  with  iodoform  gauze.     The  patient  made  a  complete  recovery. 

Histologic  examination  of  the  tissue  showed  newly  formed  connective  tissue, 
but  without  any  evidence  of  an  epithelial  lining. 

567 


568 


THE    UMBILICUS    AND    ITS    DISEASES. 


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Fig.  241. — Infected  Urachal  Remains. 
The  umbilicus  is  prominent  and  wells  out.  The  recti  muscles  have  been  retracted,  exposing  a  hard,  indurated 
mass.  Its  walls  were  exceedingly  dense,  in  places  fully  2  cm.  thick,  and  as  hard  as  gristle.  The  cavity  was  irregular 
i  r.  i. iii  line  and  contained  about  50  c.c.  of  brownish,  grumous  contents.  On  histologic  examination  the  walls  of  the  mass 
were  found  to  be  composed  of  dense  fibrous  tissue  and  the  cavity  was  lined  with  granulation  tissue.  No  attempt  was 
made  to  remove  the  mass.  The  cavity  was  wiped  out  and  packed,  and  in  a  few  weeks  the  mass  had  literally  melted 
away,  leaving  a  perfectly  soft  abdominal  wall.     The  patient  at  the  present  time  (March  1,  1916)  is  perfectly  well. 


URACHAL    INFECTIONS.  569 

The  patient  has  since  remained  absolutely  well.  In  this  case  the  situation  of 
the  tumor  left  little  or  no  doubt  that  we  were  dealing  with  remains  of  the  urachus 
which  had  undergone  a  low  grade  of  infection.  The  rapidity  with  which  the 
inflammatory  tissue  literally  melted  away  after  drainage  was  established  was 
remarkable. 

CLINICAL  COURSE. 

One  of  the  first  symptoms  is  a  feeling  of  pain  or  discomfort  in  the 
lower  abdomen.  As  the  process  advances,  the  pain  may  be  intermittent  in  char- 
acter, as  noted  in  my  case,  or  sudden  and  violent,  as  experienced  in  Page's  case. 
Arrou's  patient,  a  soldier,  had  such  abdominal  discomfort  that,  when  on  the 
march,  he  walked  with  his  body  bent  forward.  Vaussy's  patient  experienced 
great  abdominal  pain,  which  was  intensified  on  inspiration. 

A  moderate  degree  of  fever  was  noted  in  Arrou's,  Page's,  Vaussy's  cases, 
and  in  Weiser's  Case  I.     My  patient  also  had  some  fever  and  also  night-sweats. 

As  often  happens  when  pus  is  forming,  some  patients  had  a  loss  of  appetite. 
Page's  patient  -was  nauseated,  and  Baldwin's  suffered  a  good  deal  from  vomiting. 
Page's  patient  had  diarrhea,  and  in  Hornig's  case  there  was  loss  of  weight.  Vaussy's . 
patient  was  markedly  depressed.  In  those  cases  in  which  the  posterior  surface  of 
the  abscess  causes  an  inflammation  of  the  peritoneum  the  constitutional  symptoms 
will  be  more  marked. 

From  Weiser's  Case  II  we  get  a  graphic  picture  of  the  alarming  symptoms  that 
may  develop:  "On  admission  her  temperature  was  101.2°  F.,  pulse  172,  respira- 
tions, 30.  The  child  was  pale  and  emaciated,  and  had  a  dry  tongue  and  an 
anxious  expression.  She  complained  bitterly  of  abdominal  pain,  and  the  entire 
abdomen  was  tender,  especially  so  about  the  umbilicus,  and  the  entire  abdomen  was 
greatly  distended  and  board-like.  A  positive  diagnosis  was  not  made  prior  to 
operation,  but  tubercular  peritonitis  and  suppurative  urachal  cyst  were  both 
considered." 

There  are,  as  a  rule,  no  bladder  symptoms.  In  Van  Hook's  six- 
months-old  patient,  however,  the  urine  was  quite  turbid.  In  Weiser's  seventy- 
five-year-old  woman  there  had  been  frequent  micturition  for  a  month  prior  to 
operation.  This  absence  of  vesical  symptoms  stands  out  in  sharp  contrast  to 
what  occurs  in  those  cases  in  which  the  urachal  enlargements  have  a  direct  con- 
nection with  the  bladder.     In  the  latter,  vesical  symptoms  are  the  rule. 

On  examination  of  the  abdomen  it  is  often  possible  to  detect  a  board -like 
induration  between  the  umbilicus  and  symphysis.  If  the  abdominal  walls 
are  particularly  lax,  one  may  be  able  to  grasp  the  tumor  in  the  hand  and  move  it 
from  side  to  side.  As  a  rule,  however,  this  is  possible  only  when  the  patient  is 
asleep  and  the  recti  muscles  are  relaxed. 

As  a  rule,  the  abdominal  skin  looks  perfectly  normal.  In  Van  Hook's 
case,  however,  the  umbilicus  had  a  red,  inflamed  appearance,  and  thin  pus  trickled 
from  a  small  opening  in  the  lower  umbilical  fold  when  pressure  was  made  on  the 
tumor.     The  right  inguinal  glands  were  enlarged. 

In  Weiser's  Case  II  the  umbilicus  was  surrounded  by  a  zone  of  redness,  where 
the  abscess  was  ulcerating  toward  the  surface.  In  Weiser's  seventy-five-year-old 
woman  there  was  a  copious  discharge  of  pus  from  the  umbilicus,  which  had  existed 
for  fifteen  years. 


570 


THE    UMBILICUS    AND    ITS    DISEASES. 


Although  the  abscess  usually  opens  at  the  weakest  point,  viz.,  the  umbilicus, 
nevertheless,  in  rare  instances,  a  fistulous  opening  may  develop  in  the  mid-line  be- 
tween the  umbilicus  and  bladder,  as  indicated  in  Fig.  242. 

The  Abscess  Sac.  —  The  abscess  walls  are  usually  densely  adherent  to 
the  recti  in  front  and  to  the  peritoneum  behind.  They  vary  much  in  thickness, 
some  reaching  in  places  almost  2  cm.  The  inner  surface  of  the  sac  is  usually 
smooth  and  velvety,  resembling  an  ordinary  abscess  sac.  The  contents  of  the  sac 
vary  considerably.  Sometimes  they  consist  of  ordinary  pus;  this,  in  Vaussy's 
case  and  also  in  Weiser's  seventy-five-year-old  woman,  was  very  fetid.     The  fluid 

may,  however,  be  yellowish  red,  yellow- 
ish brown,  or  brownish  in  color,  and  be 
grumous  or  ropy  in  character  and  con- 
tain necrotic  material,  which  Baldwin 
and  Doran  said  reminded  them  of  "dis- 
integrating omentum." 

From  a  careful  consideration  of 
these  cases  it  seems  to  me  that  yellow- 
ish or  brownish  contents  are  found  in 
those  in  which  a  very  low  and  slumber- 
ing grade  of  infection  has  existed,  the 
typical  pus  being  found  in  the  more 
acute  inflammations. 

In  Arrou's  case  a  calculus  the  size 
of  an  olive  was  found  in  the  sac.  It 
looked  like  a  piece  of  incompletely 
dried  mortar. 

Weiser's  seventy  -  five  -  year  -  old 
woman  had  in  the  abscess  sac  a  calculus 
that  weighed  70  grains.  As  noted  from 
his  personal  communication  to  me,  it 
was  hard,  had  a  dark-brown  surface, 
and  on  section  resembled  a  bladder- 
stone  in  color  and  appearance. 

On    histologic    examina- 
tion the  walls  of  the  sac  are  found 
composed  in  a  large  measure  of  dense 
inflammatory  tissue.     In  places  some 
non-striped  muscle  may  still  be  detec- 
ted; all  trace  of  transitional  epithelium 
is  usually  lost,  but  it  may  occasionally  be  recognized  in  the  contents  of  the  abscess. 
For  abscesses  developing  in  the  subumbilical  space  the  reader  is  referred  to  the 
investigations  of  Fischer,  given  in  detail  on  p.  263. 


Fig.  242. — A>r  Infected  Urachus  Opening  Between 
the  Umbilicus  and  Bladder.  (Schematic.) 
When  a  urachal  infection  opens,  it  is  usually  either  at 
the  umbilicus  or  bladder;  occasionally,  however,  it  per- 
forates the  abdominal  wall  below  the  umbilicus,  as  indi- 
cated here. 


TREATMENT. 
After  the  median  abdominal  incision  has  been  made  and  the  recti  have  been 
separated,  the  abscess  wall  is  at  once  encountered.     If  the  walls  are  thin,  the  cavity 
is  readily  reached,  but  at  times  it  is  necessary  to  cut  deliberately  through  from  1  to 


URACHAL    INFECTIONS.  571 

2  cm.  of  very  dense  tissue  before  the  fluid  is  readied.  The  cavity  should  be  wiped 
out,  and,  if  it  has  thick  walls,  it  should  be  curetted.  It  is  then  packed  with  gauze 
and  allowed  to  close  by  granulation.  Great  care  should  be  taken  to  avoid  opening 
the  peritoneal  cavity.  It  is  astonishing  to  see  the  rapidity  with  which  the  scar 
tissue  disappears  as  the  result  of  adequate  drainage.  In  those  cases  in  which  the 
urachus  is  enlarged  and  adherent  to  the  sac,  and  where  this  tube  can  be  readily 
reached,  it  is  advisable  to  ligate  and  cut  it,  as  there  is  a  possibility  of  urine  escaping 
later  from  the  abscess  sac. 

CASES  OF  ABSCESS  OF  THE  ABDOMINAL  WALL  DUE  TO  INFECTION  OF  REMAINS 
OF  THE  URACHUS,  AND  NOT  COMMUNICATING  WITH  THE  BLADDER. 

I  have  not  cited  all  the  recorded  cases,  but  have  included  only  those  that  are 
especially  convincing. 

Suppurating  Cyst  of  the  Urachus.  —  Arrou*  reported  the 
case  of  a  patient  operated  upon  by  Tricot.  A  soldier,  who  gave  absolutely  no 
history  of  bladder  trouble,  complained  of  vague  pain  in  the  umbilical  region.  The 
pain  became  acute,  and  during  his  march  he  had  to  bend  forward.  He  had  no 
nausea  or  intestinal  disturbances;  urination  was  normal,  the  temperature  unaltered. 

Examination  revealed  a  plaque  as  large  as  a  hand  a  little  below  the  umbilicus. 
This  was  painful,  but  there  was  neither  edema  nor  reddening.  Gradually  a  little 
swelling  was  noted.     The  patient  had  some  pain  and  fever. 

Operation. — An  exploratory  operation  under  local  anesthesia  was  determined 
upon,  the  condition  being  thought  to  be  due  to  an  abscess  of  the  abdominal  wall. 
But  almost  as  soon  as  the  patient  reached  the  operating  room  an  escape  of  a  small 
amount  of  pus  was  noted  coming  from  the  lower  margin  of  the  umbilicus.  A 
probe  introduced  into  the  small  orifice  descended  downward  and  backward  into 
the  cavity,  which  was  6  cm.  long  in  its  vertical  direction.  The  patient  was  at  once 
anesthetized,  and  a  cavity  was  opened;  this  proved  to  be  as  large  as  a  manda- 
rin orange,  and  contained  a  calculus  the  size  of  an  olive,  like  a  piece  of  mortar 
incompletely  dried.  The  cyst  lining  resembled  an  inflamed  mucosa.  Unfor- 
tunately, both  sac  and  calculus  were  lost.  The  upper  end  of  the  sac  ended  at  the 
bottom  of  the  umbilicus;  the  lower  extremity  terminated  in  the  closed  cul-de-sac. 
Attached  to  the  lower  end  of  the  sac  was  a  cord  the  size  of  the  little  finger;  this 
cord  gradually  became  smaller  and  terminated  in  the  fundus  of  the  bladder. 
There  is  no  doubt  that  it  was  the  urachus. 

The  peritoneum  was  opened  above  and  laterally,  the  intestine  projected.  The 
urachus  was  cut  across  with  a  cautery  at  a  point  several  millimeters  above  the 
bladder.  The  sac  was  completely  removed  and  the  wound  closed.  The  patient 
made  a  good  recovery. 

Abscess  Between  Umbilicus  and  Pubes.f-  "Mrs.  C.  L. 
R.,  aged  thirty-three,  Shenandoah,  Ohio.  Physician,  Dr.  J.  M.  Fry.  Married 
twelve  years;  one  child,  aged  eleven  years;  labor  normal;  no  miscarriages;  appe- 
tite fair,  but  much  vomiting;  kidneys  normal;  menstruation  normal.  Patient 
had  suffered  from  her  present  trouble  for  about  a  year,  but  no  diagnosis  had  been 

*  Arrou:  Kyste  suppure  de  l'ouraque.  '  Bull,  et  Mem.  de  la  Soc.  de  chir.,  Paris,  1910,  xxxvi, 
832. 

t  Baldwin,  J.  F.:  Large  Cysts  of  the  Urachus.     Surg.,  Gyn.,  and  Obst.,  June,  1912,  xiv,  636. 


572  THE    UMBILICUS    AND    ITS    DISEASES. 

made  until  about  three  weeks  before  I  saw  her,  which  was  March  29,  1901.  In  the 
previous  July  she  had  had  a  feeling  of  fulness  and  was  as  large  as  though  pregnant 
six  months.  In  September  much  of  this  fulness  disappeared,  but  it  again  increased. 
When  I  saw  her,  the  uterus  was  pushed  forward  and  to  the  right  by  a  tumor,  which 
did  not  seem  to  involve  the  uterus  but  which  extended  from  the  pubes  to  the 
umbilicus.  This  tumor  was  cystic,  and  apparently  about  the  size  of  an  adult  head. 
It  could  not  be  said  to  be  movable,  but  did  not  seem  to  be  very  firmly  fixed.  Dr. 
Hunter  Robb,  of  Cleveland,  and  myself  saw  the  patient  together  in  consultation, 
and  assumed  that  the  tumor  was  ovarian. 

"She  came  to  Columbus  and  was  operated  on  April  24,  1901,  Dr.  Fry  being 
present.  When  under  the  anesthetic  the  uterus  was  found,  as  before,  pushed  for- 
ward against  the  bladder,  and  the  cyst  could  be  very  distinctly  mapped  out.  On 
opening  the  abdomen  we  found  the  transversalis  fascia  to  be  much  thickened.  It 
was  dissected  through  with  great  care.  On  getting  through  there  was  a  gush  of 
pus.  With  the  fingers  on  the  inside  the  incision  was  enlarged  sufficiently  for 
thorough  examination.  A  large  quantity  of  pus  was  evacuated,  together  with  a 
considerable  amount  of  more  or  less  necrotic  material,  resembling  somewhat  dis- 
integrated omentum  (as  in  one  of  the  cases  mentioned  by  Doran).  The  cavity 
having  been  entirely  cleaned  out,  the  sac  was  found  to  be  a  smooth  and  rather  thick 
membrane.  The  peritoneal  cavity  itself  had  not  been  entered.  In  the  pelvis  the 
uterus  was  found  standing  up,  as  it  were,  distinctly  in  the  cavity,  though  covered 
by  the  membrane,  as  were  also  its  appendages.  The  connection  of  the  membrane 
with  the  surrounding  parts  seemed  to  be  so  firm  as  to  render  any  attempt  at  its 
enucleation  undesirable.  The  cavity  was  therefore  drained,  the  incision  being 
only  in  part  closed. 

"Patient  stood  the  operation  well,  made  an  excellent  operative  recovery,  and 
returned  home  in  due  time.  Dr.  Fry  reported,  under  date  of  March  15,  1904,  that 
the  fistula  which  followed  the  drainage  had  closed  only  about  four  months  before. 
Patient  had  been  warned  as  to  the  probability  of  a  hernia.  Under  date  of  Sep- 
tember 17,  1911,  the  patient,  in  response  to  a  letter  of  inquiry,  reported  that  her 
health  was  as  good  as  ever.  From  her  letter  it  is  evident  that  there  is  a  small 
hernia  at  the  point  of  drainage  which  perhaps  should  be  operated  upon,  but  seems 
to  be  making  no  special  trouble.  Menstruation  perfectly  regular."  Baldwin  said 
that  the  patient  has  had  no  further  pregnancies. 

Infection  of  the  Urachus.  —  In  Bryant's*  Case  2  the  patient  was  a 
man  about  thirty  years  of  age  who  had  a  slight  epispadias.  He  had  had  for  many 
years  a  tumor  the  size  of  a  small  cocoanut  lying  between  the  umbilicus  and  the 
symphysis.  He  came  under  observation  on  account  of  great  swelling  and  tender- 
ness between  the  pubes  and  the  umbilicus.  The  condition  was  thought  to  be  due  to 
an  abscess.  The  urine  was  normal.  After  incision,  very  fetid  material  came  out, 
bu1  there  was  no  urinary  smell.  The  cavity  was  packed  with  terebene,  and  some 
days  later  urine  was  discharged  from  the  wound. 

Abscess  F  o  r  m  a  t  i  o  n  in  the  Patent  Urachus. f  —  A  female 
child,  apparently  normal  at  birth,  had  abdominal  pain  and  diarrhea  and  vomiting 
when  three  weeks  old.  When  five  months  old  she  was  sick  again,  and  the  mother 
noticed  a  protrusion  of  the  abdominal  wall  below  the  umbilicus.     The  swelling 

*  Bryant,  T.:   Brit.  Med.  Jour.,  1898,  i,  1390. 

t  Van  Hook:  Amer.  Jour.  Obst.,  New  York,  1894,  xxix,  624. 


"URACHAL    INFECTIONS.  573 

reached  the  size  of  an  orange.  Hot  applications  resulted  in  an  opening  at  the 
umbilicus,  with  the  discharge  of  a  large  quantity  of  pus.  Later  on  cystitis  developed 
and  pus  continued  to  be  discharged  through  the  umbilicus. 

Van  Hook  examined  the  child  when  it  was  six  months  old.  She  urinated  re- 
peatedly during  the  examination.  The  urine  was  quite  turbid.  The  umbilicus 
projected  slightly  upward  and  forward  and  was  apparently  pushed  in  this  direction 
by  a  tumefaction  the  size  of  a  small  apple,  which  also  pushed  forward  the  abdominal 
wall  between  the  umbilicus  and  the  pubes.  The  umbilicus  had  a  red,  inflamed 
appearance.  A  thin  pus  trickled  from  the  small  opening  in  the  lower  umbilical 
fold  when  pressure  was  made  on  the  tumor.  There  was  swelling  of  the  right 
inguinal  glands. 

Under  chloroform  a  probe  was  passed  down  almost  to  the  pubes,  but  did  not 
enter  the  bladder.  The  opening  was  dilated  and  a  drainage-tube  put  in.  Recovery 
followed  in  a  week. 

An  Infected  Urachal  Cyst.' —  Hornig*  reviews  the  literature  and 
reports  a  case  from  Trendelenburg's  clinic. 

The  patient  was  a  girl,  three  years  and  nine  months  old.  For  several  weeks  she 
had  complained  of  painful  urination.  For  eight  days  the  mother  had  noticed 
swelling  of  the  abdomen.  The  child  had  lost  weight.  The  father  said  that  she 
had  often  felt  sick,  and  in  the  spring  had  remained  in  bed  for  two  days. 

Operation  (December  4,  1902).- — The  umbilicus  bulged  out,  forming  a  nodule 
the  size  of  a  cherry.  It  was  bluish  red  and  covered  with  thin  skin.  From  the 
umbilicus  to  the  symphysis  the  abdomen  was  half-ball-shaped  from  tension. 
Palpation  met  with  a  tense  resistance.  The  umbilical  swelling  collapsed  while  the 
child  was  being  bathed,  and  yellowish-red,  thick,  fluid  masses  escaped.  On  cathe- 
terization the  urine  was  perfectly  clear  and  transparent;  it  contained  no  albumin 
nor  sediment.  The  umbilical  fluid  contained  staphylococci,  and  microscopically 
many  flat  cells.  After  the  bladder  had  been  emptied  the  half-ball-shaped  swelling 
between  the  umbilicus  and  the  symphysis  became  less  prominent,  and  by  rectal 
examination,  with  one  hand  on  the  abdomen,  the  surgeon  could  make  out  very 
clearly  a  cystic  tumor. 

The  fistulous  opening  was  closed  to  prevent  infection.  The  incision  encircled 
the  umbilicus  and  extended  to  2  cm.  above  the  symphysis.  The  anterior  wall  of  the 
cyst  was  exposed.  On  account  of  the  danger  of  peritonitis  total  extirpation  of  the 
cyst  was  not  attempted,  but  the  anterior  cyst-wall  and  the  umbilicus  were  removed. 
A  finger  in  the  cyst  showed  that  it  extended  downward  behind  the  symphysis,  and 
that  it  ended  blindly  in  the  pelvis.  A  catheter  introduced  into  the  bladder  could 
be  felt  behind  and  to  the  left.  The  cyst-wall  was  curetted  with  a  sharp  curette 
to  remove  any  epithelial  lining.  A  drain  was  laid  and  the  opening  closed.  By 
January  13,  1903,  only  a  small,  granulating  strip,  5  mm.  wide,  remained. 

On  microscopic  examination  no  epithelial  lining  of  the  cyst  could  be  found. 
The  walls  were  composed  of  connective  tissue,  showing  marked  round-cell  infiltra- 
tion. They  also  contained  smooth  muscle-fibers.  Although  the  epithelium  was 
missing,  Hornig  felt  that  the  smooth  muscle  was  all  that  was  necessary  for  diagnosis. 

A  Case  of  Hardening  of  the  Linea  Alba  and  Umbil- 
icus. —  In  some  healthy  persons  Leggf  says  there  may  be  felt  in  the  linea  alba, 

*  Hornig,  Paul:   Zur  Kasuistik  der  Urachuscysten.     Inaug.  Diss.,  Leipzig,  1905. 
t  Legg,  J.  W.:  Saint  Bartholomew's  Hospital  Reports,  1880,  xvi,  251. 


574  THE    UMBILICUS    AND    ITS    DISEASES. 

between  the  pubes  and  the  umbilicus,  a  certain  thickness  or  firmness  which  is  not, 
however,  very  marked.  He  cites  an  interesting  case  in  which  the  linea  alba  be- 
tween the  pubes  and  the  umbilicus  was  one  inch  thick,  a  new  growth  having  its 
seat  apparently  in  the  subperitoneal  tissue.  This  growth  was  white,  dense,  tough, 
and  much  thicker  on  the  left  than  on  the  right  of  the  mid-line.  The  omentum  was 
thickened.  The  stomach  was  small,  constricted,  and  adherent  to  the  omentum. 
No  microscopic  examination  was  made.  [The  possibility  of  a  malignant  abdominal 
growth  in  this  case  cannot  be  excluded. — T.  S.  C] 

A  Partially  Patent  and  Infected  Urachus.  —  Lexer*  re- 
ports a  case  coming  under  the  observation  of  Delageniere.  The  patient  was  a  boy, 
five  and  a  half  years  old,  who  had  a  fistula  dating  from  early  childhood.  At  the 
sixth  month  a  small  tumor  at  the  umbilicus  opened.  Delageniere  cut  around  and 
then  entered,  behind  the  umbilicus,  a  pocket  filled  with  granulation  tissue.  Its 
lower  portion  communicated  with  the  urachus.  In  dissecting  this  out  he  opened 
the  peritoneum  and  could  feel  a  string  of  the  urachus  passing  downward  to  the 
bladder.  It  was  isolated  for  3  cm.  and  cut  across.  The  lumen  was  turned  in  and 
closed  with  sutures.  The  fistula  healed  as  the  result  of  this  procedure,  which 
Delageniere  spoke  of  as  partial  resection  of  the  urachus.  The  child  remained 
healthy. 

An  Infected  Cyst  of  the  Urachus.  —  Page's t  patient  was  a 
man  thirty-six  years  of  age,  married,  and  previously  in  good  health.  In  March, 
1899,  he  had  dull  pain  about  the  fundus  of  the  bladder.  The  pain  was  inter- 
mittent, ceased,  and  reappeared  the  second  year.  In  July,  1901,  he  had  sudden 
violent  cramps  in  the  abdomen,  followed  by  diarrhea.  The  diarrhea  ceased  in 
two  weeks,  but  the  pain  continued.     Page  suspected  appendicitis. 

On  admission  the  patient  walked  bent  over.  He  had  great  pain  in  the  hypo- 
gastric region.  His  temperature  was  102.5°  F.,  pulse  100.  He  was  nauseated. 
Examination  disclosed  a  circumscribed  mass,  the  size  of  an  average  orange,  which 
lay  between  the  umbilicus  and  pubes,  and  seemed  to  be  in  the  abdominal  wall. 
The  patient  had  had  a  chill  the  night  before.  Dr.  F.  L.  Taylor  suggested  a  sup- 
purating cyst  of  the  urachus. 

Operation. — Incision  three  inches  long  over  the  mass.  In  cutting  through  the 
fascia  the  tissues  were  found  to  be  dense  and  hard.  The  operator  entered  a  cavity 
containing  four  ounces  of  thick,  flaky  fluid,  yellowish-brown  in  color.  The  abscess 
cavity  was  large;  the  walls  were  smooth  and  very  thick.  In  lengthening  the  in- 
cision the  peritoneum  was  accidentally  opened.     It  was  at  once  closed. 

The  recovery  was  slow.  The  cavity  gradually  became  obliterated.  The 
sinus  had  to  be  curetted  several  times,  but  it  healed  permanently.  The  man  had 
formerly  weighed  115  pounds;  he  then  weighed  145. 

Subperitoneal  Phlegmon  of  the  Anterior  Abdominal 
Wall  Without  Appreciable  Cause,  Opening  Below  the 
Umbilicus;  Rapid  Healing.!  —  On  p.  5  Vaussy  gives  the  history  of 
phlegmonous  subperitoneal  inflammation  of  the  anterior  abdominal  wall,  and  on 
p.  6  says  that  Velpeau,  Boyer,  Nelaton  and  Vidal,  had  cited  in  their  publications 

*  Lexer,  K.:    I'eber  die  Behundlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  1898,  lvii,  73. 
f  Pago,  Charles  C:  The  Post-Graduate,  New  York,  1902,  xvii,  1094. 

{Vaussy:     Des  phlegmons  sous-periton<£aux  de  la  paroi  abdominale  anterieure.     These  de 
Paris,  1875,  No.  445,  Obs.  2. 


URACHAL    INFECTIONS.  575 

several  examples  of  vast  purulent  accumulations  developing  between  the  peritoneum 
and  the  anterior  abdominal  wall.  On  p.  25  he  gives  Observation  2.  A  boy,  aged 
eleven,  had  at  first  complained  of  malaise,  fever,  and  lack  of  appetite,  and  later  of 
extreme  pain  in  the  hypogastric  region.  This  was  increased  on  inspiration.  For 
a  time  the  pain  became  general  throughout  the  entire  abdomen.  The  parents  soon 
noticed  a  swelling  in  the  abdomen  below  the  umbilicus.  When  admitted  (October 
26,  1875)  to  the  hospital,  the  boy  showed  a  great  deal  of  depression,  had  fever, 
no  appetite,  but  gave  no  history  of  chills  or  vomiting. 

On  inspection  a  tumor  was  found  extending  from  the  umbilicus  to  the  pubes. 
It  was  in  the  median  line,  and  extended  over  to  the  left  5  cm.  and  to  the  right  as  far 
as  the  crest  of  the  ilium.  The  tumor  was  hard,  possibly  fluctuating,  but  this  could 
not  be  determined  on  account  of  the  patient's  pain.  It  suggested  in  contour  a 
markedly  distended  bladder.  The  skin  was  of  normal  color;  there  was  no  redness 
nor  edema.  Rectal  examination  was  negative.  It  was  decided  that  the  condition 
was  due  to  a  subperitoneal  phlegmon  of  the  anterior  abdominal  wall.  It  was 
impossible  to  determine  the  cause  of  the  phlegmon,  as  the  child  had  never  been 
injured,  nor  had  he  had  typhoid  fever.  The  hypogastric  region  remained  painful, 
the  tumor  became  fluctuating,  and  a  small  red  point  the  size  of  a  50-centime  piece 
appeared  immediately  below  the  umbilicus  in  the  median  line.  Poultices  were 
applied.  The  pain  and  redness  persisted,  and  there  developed  a  small  tumor  the 
size  of  a  cherry.  Fluctuation  being  evident,  a  small  incision  was  made  with  a 
bistoury  and  an  enormous  quantity  of  pus  escaped.  This  had  a  very  fetid  odor, 
but  did  not  in  any  way  suggest  stercoraceous  material.  By  the  eleventh  of 
November  the  fistula  had  closed  and  the  child  left  the  hospital.  The  cause  of  the 
inflammation  in  this  case  was  not  clear. 

[The  history,  which  is  characteristic  of  such  cases,  suggests  remains  of  the 
urachus  which  had  become  inflamed. — T.  S.  C] 

Suppuration  of  a  Urachal  Cyst.  —  In  Weiser's  Case  2  the  pa- 
tient was  a  girl,  eleven  years  old,  who  was  admitted  to  the  Mercy  Hospital  on  April 
11,  1905.  The  child  had  complained  for  several  days  of  headache  and  vomiting 
and  had  gradually  developed  slight  tenderness  and  some  pain  in  the  abdomen. 
At  first  there  had  been  no  localized  tenderness  and  very  little  distention.  One 
week  prior  to  admission  general  flatness  had  been  noted  with  fluctuation.  The 
abdomen  had  become  more  and  more  distended.  On  admission  her  temperature 
was  101.2°  F.;  pulse,  172;  respirations,  30.  The  child  was  pale  and  emaciated  and 
had  a  dry  tongue  and  an  anxious  expression.  She  complained  bitterly  of  ab- 
dominal pain,  and  the  entire  abdomen  was  tender,  especially  about  the  umbilicus, 
greatly  distended  and  board-like.  The  flatness  extended  from  the  umbilicus  to 
the  symphysis,  and  from  a  point  two  inches  to  the  right  of  the  median  line 
almost  completely  into  the  loin  on  the  left.  Surrounding  the  umbilicus  was  a  zone 
of  redness  l^g  inches  in  diameter,  which  represented  an  area  through  which  the 
abscess  was  ulcerating  toward  the  surface.  A  positive  diagnosis  was  not  made 
prior  to  operation,  but  tubercular  peritonitis  and  a  suppurative  urachal  cyst  were 
both  considered. 

Under  anesthesia  the  abdomen  was  opened  in  the  mid-line  between  the  umbili- 
cus and  symphysis.  Absence  of  the  peritoneum  made  a  diagnosis  quickly  possible. 
The  abdominal  cavity  was  divided  into  two  compartments  by  the  sac-wall,  which 
*  Weiser,  W.  R.:  Annals  of  Surgery,  1906,  xliv,  529. 


576 


THE    UMBILICUS    AND    ITS    DISEASES. 


had  displaced  the  intestines  almost  entirely  to  the  right  side  of  the  cavity  and  walled 
them  off.  Almost  the  entire  left  side  below  the  umbilicus  was  filled  with  the  cyst, 
which  had  ruptured,  as  shown  in  Fig.  243.  Except  at  the  point  of  rupture,  the  cyst 
contents  were  entirely  extraperitoneal,  although  occupying  so  large  a  part  of  the 
abdominal  cavity.  Free  pus  to  the  amount  of  several  pints  was  confined  to  the 
left  side,  and  was  not  in  contact  with  the  intestines.  The  position  occupied  by  the 
mass  is  fairly  well  shown  in  Fig.  243.  The  urachus  was  patulous  down  to  within 
three-eighths  of  an  inch  of  the  bladder,  and  was  ligated  at  this  point.  So  much  of 
the  sac  as  could  be  dissected  out  without  tearing  up  the  limiting  wall  was  taken 

away,  and  the  abscess  cavity  washed  out  and  drained 
with  a  coffer-dam  drain  of  iodoform  gauze.  An  area 
2  x  4j/2  inches  was  bare  of  peritoneum  at  the  site 
of  the  wound,  but  there  was  no  trouble  from  this 
source. 

A  Small  Urachal  Cyst  Showing 
Inflammation.*  — ■  Case  23.  Autopsy  No. 
260,  1881. — The  body  was  that  of  a  man,  sixty-three 
years  old,  dead  of  arteriosclerosis,  hypertrophy  and 
dilatation  of  the  heart,  emboli  of  the  lungs,  general 
edema,  hypertrophy  of  the  prostate,  catarrhal  cysti- 
tis. The  bladder  was  pear-shaped,  and  its  vertex 
appeared  to  reach  to  within  4  cm.  of  the  umbilicus. 
When  it  was  opened  at  the  upper  end,  tenacious  and 
slimy  pus  escaped.  An  abscess  lay  above  and  behind 
the  top  of  the  bladder.  The  bladder  itself  was  11.5 
cm.  long,  and  the  distance  from  the  vertex  to  the 
umbilicus  was  8.4  cm.  The  bladder  appeared  to  be 
independent  of  the  first  abscess  (a) .  Above  the  sur- 
face of  the  larger  abscess  (a)  was  a  smaller  one  (6), 
the  size  of  a  bean.  The  cavities  of  both  of  these  were 
reddish.  Above  this  point  the  urachus  appeared  as 
a  cord,  accompanied  by  the  umbilical  arteries.  The 
mucosa  of  the  bladder  was  pale,  not  ulcerated.  On 
the  mucosa  of  the  vertex  of  the  bladder  was  an  ex- 
travasation the  size  of  a  pin-head,  and  in  the  middle 
of  this  was  a  punctiform  depression  through  which  a 
bristle  could  be  passed  into  abscess  (a).  The  cavity  of  abscess  (a)  was  1  cm.  long, 
0.6  cm.  broad.  From  this  abscess  cavity  a  bristle  could  be  passed  into  abscess 
h  l  so  that  the  connection  between  the  two  was  easily  followed.  From  abscess 
(b)  the  urachus  could  be  traced  0.5  cm.  toward  the  umbilicus.  Microscopic 
examination  of  the  walls  of  the  abscesses  (a)  and  (6)  showed  that  they  were  in- 
flammatory urachal  cysts.  In  some  places  the  characteristic  several  layers  of 
epithelium  were  in  evidence;  at  other  points  the  inner  surface  of  the  cyst  was 
ulcerated  and  the  connective  tissue  showed  small-round-cell  infiltration.  The 
entire  length  of  the  urachus  in  this  case  was  4  cm. 

*  Wutz,  J.  15.:   Tiber  (Jrachus  and  I'raehuscysten.     Virchows  Arch.,  1883.  xcii,  387. 


Fig.  243. — Urachal  Cyst.  'After 
W.  R.  Weiser,  Case  2,  Fig.  2.) 
The  urachus  was  patulous  down 
to  within  three-eighths  of  an  inch  of 
the  bladder.  Above  that  it  had  dilated 
into  a  large  cyst.  The  urachus  was 
ligated  and  severed  and  as  much  as 
possible  of  the  suppurating  cyst-wall 
was  cut  away.  The  abscess  cavity 
was  washed  out  and  drained. 


URACHAL    INFECTIONS.  577 


LITERATURE   CONSULTED   ON   ABSCESS   IN   THE   ANTERIOR   ABDOMINAL   WALL, 

BETWEEN  THE  UMBILICUS  AND  THE  SYMPHYSIS,  DUE  TO  INFECTION  OF 

URACHAL  REMAINS  AND  OF  URACHAL  CYSTS. 

Arrou:   Kyste  suppure  de  l'ouraque.     Bull,  et  Mem.  de  la  Soc.  de  chir.,  Paris,  1910,  xxxvi,  832. 

Baldwin,  J.  F.:  Large  Cysts  of  the  Urachus.     Surg.,  Gyn.,  and  Obst.,  June,  1912,  xiv,  636. 

Bryant,  T.:   Brit.  Med.  Jour.,  1898,  i,  1390. 

Fischer,  H.:  Die  Eiterungen  im  subumbilicalen  Raume.  Volkmann's  Sammlung  klin.  Vortrage, 
n.  F.,  Xo.  89  (Chir.  No.  2-1),  Leipzig,  189-1,  519. 

Heinrich:  Ueber  beschriinkte,  sogenannte  aussere  oder  tuberculose  Peritonitis  bei  Kindern,  oder 
iiber  Entziindung  der  subkutanen  Sehicht  der  Bauchwand  und  iiber  die  Bildung  von  Abszessen 
und  Verhartungen  daselbst.     Jour.  f.  Kinderkrankheiten,  1849,  xii,  6. 

Van  Hook,  W. :  Abscess  Formation  in  the  Patent  Urachus.  Amer.  Jour.  Obst.,  New  York, 
1894,  xxix,  624. 

Hornig,  P.:   Zur  Kasuistik  der  Urachuscysten.     Inaug.  Diss.,  Leipzig,  1905. 

Legg,  J.  AY. :  Cases  of  Hardening  of  the  Linea  Alba  and  Umbilicus.  Saint  Bartholomew's  Hos- 
pital Reports,  1880,  xvi,  251. 

Lexer,  E.:  Ueber  die  Behandlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  189S,  lvii,  73. 

Nicaise:  Ombib'c.  Dictionnaire  encycloped.  des  sciences  medicales,  Paris,  1881,  2.  ser.,  xv, 
140. 

Page,  C.  C. :  Cyst  of  the  Urachus.     The  Post-Graduate,  New  York,  1902,  xvii,  1094. 

Vaussy,  F. :  Des  phlegmons  sous-peritoneaux  de  la  paroi  abdominale  anterieure.  These  de  Paris, 
1875,  No.  445. 

Weiser,  W.  R.:  Cysts  of  the  Urachus.     Annals  of  Surg.,  1906,  xliv,  529. 

Wutz,  J.  B.:  Ueber  Urachus  and  Urachuscysten.     Virchows  Arch.,  1883,  xcii,  387. 


38 


CHAPTER  XXXIV. 

URACHAL    CAVITIES    BETWEEN    THE    SYMPHYSIS    AND    UMBILICUS 
COMMUNICATING  WITH  THE  BLADDER  OR  UMBILICUS  OR 

WITH  BOTH. 

General  consideration. 
Symptoms. 

Differential  diagnosis. 
Treatment. 

Instance  of  a  urachal  cavity  between  the  symplrysis  and  umbilicus  and  communicating  with  the 
bladder  or  umbilicus  or  both. 

Figs.  244  and  245  graphically  illustrate  urachal  cavities  communicating  with 
the  bladder.  Fig.  246  shows  in  a  schematic  manner  the  way  in  which  a  distended 
urachus  may  open  at  the  umbilicus.  Dilatation  of  the  urachus  with  the  escape  of 
urine  from  both  the  bladder  and  umbilicus  is  indicated  in  Fig.  247,  while  in  Fig.  248 
we  see  the  tremendous  quantities  of  stagnant  urine  that  niay  be  forced  little  by 
little  into  the  pervious  urachus  when  the  bladder  contracts  during  micturition. 
Finally,  the  valve-like  opening  is  overcome  and  there  is  a  sudden  gush  of  ammonia cal 
urine  from  the  urethra;  or  an  opening  may  develop  at  the  umbilicus;  or  the  urine 
may  escape  from  both  the  urethra  and  the  umbilicus. 

Sex.  —  Of  the  cases  here  recorded,  and  in  which  data  as  to  the  sex  are  avail- 
able, 14  were  in  males  and  12  in  females. 

Age.  —  The  youngest  patient  (Savory's)  was  thirteen  months  old.  Weiser's 
patient,  a  woman  of  seventy-five,  was  the  oldest.     The  age  table  is  as  follows: 

Under  ten  years  of  age 4  cases 

Between  ten  and  twenty  years  of  age 2     " 

Between  twenty  and  thirty  years  of  age 7     " 

Between  thirty  and  forty  years  of  age 1  case 

Between  forty  and  fifty  years  of  age 4  cases 

Between  fifty  and  sixty  years  of  age 1  case 

Between  sixty  and  seventy  years  of  age 1    " 

Over  seventy  years  of  age 2  cases 

These  figures  are  of  only  relative  value.  Bramann's  patient,  who  came  under 
observation  at  twelve,  had  definite  symptoms  when  nine  years  old.  Freer's  pa- 
tient came  under  treatment  at  fifty-four,  but  from  the  history  it  was  evident  that 
symptoms  were  first  noted  when  the  patient  was  seven  years  old.  Newman's 
patient  was  thirty-nine  years  old,  but  he  had  had  an  enlargement  in  the  lower 
abdomen  as  long  as  he  could  remember.  Vaughan's  patient,  a  man  of  forty,  had 
experienced  pain  in  the  suprapubic  region  when  seventeen. 

SYMPTOMS. 
The  chief  symptoms  are  those  referable  to  the  bladder  and  to  the  development 
of  a  tumor  between  the  symphysis  and  umbilicus.     When  infection  occurs,  consti- 
tutional disturbances  are  superadded. 

578 


URACHAL    CAVITIES    AND    INFECTIONS. 


579 


A  reference  to  the  accompanying  histories  will  show  that  the  vesical 
s  y  m  p  t  o  m  s  varied  greatly.  Some  patients  complained  of  frequent  micturition, 
others  of  incontinence,  while  others  had  difficult  micturition,  retention,  or  an  almost 
total  inability  to  void. 

In  some  the  vesical  symptoms  had  been  of  short  duration;   others  had  had  defi- 


Fig.  244. — A  Dilated  Urachus  Communicating  with 
the  Bladder.  (Schematic.) 
Where  such  a  condition  exists,  when  the  bladder  con- 
tracts during  micturition  part  of  the  urine  escapes  from 
the  urethra  and  part  may  be  forced  into  the  urachal  sac. 
Finally  the  urachal  sac  will  empty  itself  into  the  bladder. 


Fig.  245. — Large  Accumulation  op  Urine  in  a 
Partially  Patent  Urachus.  (Schematic.) 
Some  patients  give  a  history  of  cystitis,  and  a  few 
months  later  a  hard,  globular  tumor  is  noted  between 
the  umbilicus  and  symphysis.  After  the  bladder  has 
been  emptied  with  a  catheter  the  tumor  still  persists. 
Finally,  after  a  very  large  amount  of  fluid  has  accumu- 
lated, it  may  all  be  discharged  at  once  through  the 
bladder,  or  the  urachus  may  open  at  the  umbilicus, 
allowing  the  accumulated  urine  and  pus  to  escape  by 
this  avenue.  In  these  cases  there  is  usually  a  periodic 
filling  and  emptying  of  the  urachal  sac. 


nite  bladder  disturbances  for  years.  In  Patel's  case,  for  example,  a  child  three 
years  old  had  had  incontinence  of  urine  day  and  night  since  birth,  the  urine  being 
passed  involuntarily  and  at  frequent  intervals.  In  Freer's  patient,  a  woman  fifty- 
four  years  old,  vesical  symptoms  were  first  noted  when  she  was  seven  years  old. 
Schnellenbach's  patient,  who  was  sixty-six  years  old,  had  had  frequent  micturition 
for  one  year  and  pressure  was  necessary  to  start  the  flow.     When  the  patient  was 


5S0 


THE    UMBILICUS    AND    ITS    DISEASES. 


catheterized,  1500  c.c.  of  urine  came  away.  Worster's  patient  gave  a  history 
of  having  developed  a  cystitis  with  incontinence  after  diphtheria,  and  eleven 
years  before  coming  under  observation  had  passed  a  large  amount  of  pus  from  the 
urethra. 

In  some  cases  the  urine  was  turbid  and  contained  pus  and  occasionally  blood. 
In  other  cases  the  urine  was  clear;  occasionally,  as  in  Graf's,  Lexer's,  and  Matthias' 


Fig.  24(i. — Ax  Infected  Urachus  Opening  at 
the  Umbilicus.  (Schematic.) 
1  (ccasionally  urachal  remains  become  in- 
fected,  and  after  a  time  open  at  the  umbilicus.  In 
i  hose  cases  in  which  the  vesical  end  of  the  urachus 
i-  closed  i  here  is  no  escape  of  urine  from  the  um- 
bilicus, the  discharge  being  purulent  or  slimy  in 
character. 


Fig.  217. — A  Patent  Urachus  Dilated  in  its  Middle  Por- 
tion.     (Schematic.) 
In  such  cases  the  middle  portion  of  the  urachus  may  be- 
come markedly  distended,  sometimes  containing  a  liter  or  more 
of  decomposing  urine.     (See  Fig.  248.) 


cases,   the  patients  had  previously  had  a  gonorrheal  infection.     This  naturally 
confused  the  clinical  picture  to  some  extent. 

P  a  i  if.  —  More  or  less  pain  in  the  lower  abdomen  was  a  frequent  symptom. 
In  Bourgeois'  ease  there  was  an  almost  insupportable  feeling  of  tension  in  the  lower 
abdomen,  and  the  suprapubic  region  was  particularly  sensitive  after  fatigue.  In 
Matthias'  case  there  was  a  feeling  of  pressure  in  the  lower  abdomen,  accompanied 
by  malaise.     Worster's  patient  had  to  bend  forward  at  an  angle  of  45  degrees  to 


URACHAL    CAVITIES    AND    INFECTIONS. 


581 


get  relief,  and  was  incapable  of  stooping  down  to  pick  up  anything.  Newman's 
patient  suffered  much  pain,  walked  with  difficulty,  and  had  an  anxious  expression. 
Hind's  patient  had  a  steady  pain  in  the  lower  abdomen.  Suddenly  something 
gave  way,  there  was  a  feeling  of  relief,  and  a  large  amount  of  pus  escaped  from  the 
bladder. 

The  Umbilicus.  —  With  the  progress  of  the  disease  the  umbilicus  in 
about  half  of  the  cases 
became  inflamed  and  rup- 
tured, with  the  escape  of 
pus,  and  later  of  urine.  In 
Bourgeois'  case  a  small,  soft, 
red  tumor  the  size  of  an 
almond  developed  at  the 
navel.  During  micturition 
it  would  become  prominent 
and  painful.  It  was  opened 
and  urine  escaped. 

Bramann's  patient,  two 
years  after  vesical  symp- 
toms had  been  noted,  had 
a  sudden  discharge  of  urine 
from  the  umbilicus.  In 
Hastings'  case  the  urine  for 
a  time  ceased  entirely  to 
pass  from  the  urethra.  On 
one  occasion,  when  the  pa- 
tient had  not  voided  at  all 
for  a  long  period,  there  was 
a  sudden  gush  of  two  quarts 
from  the  umbilicus. 

Lexer's  patient,  one  and 
a  half  years  after  the  onset 
of  symptoms,  complained  of 
pain  in  the  umbilical  region. 
The  tissues  swelled  up,  be- 
came red,  and  a  quantity  of 
purulent  material  escaped. 
On  pressure  pus  and  urine 
were  discharged  from  the 
umbilicus.  Savory's  patient 
developed  a  tense  umbilical 

swelling  two  to  three  inches  in  diameter.  This  was  tender  during  micturition.  It 
was  opened  later,  pus  escaped,  and  finally  nearly  all  the  urine  was  passed  by  this 
avenue. 

In  Schnellenbach's  case  there  was  pain  in  the  umbilical  region,  followed  by  the 
escape  of  pus.  Vaughan's  patient  had  poultices  applied  to  the  umbilical  region. 
Two  weeks  later  pus  and  urine  passed  from  the  umbilicus.  Occasionally  the  open- 
ing would  close  for  a  couple  of  days.     This  closure  was  accompanied  by  much  pain, 


Fig.    248.- 


Urine    in 


Accumulation  op  a  Large  Quantity 
Urachal  Pouch.  (Schematic.) 
Occasionally  the  urachal  pouch  is  very  large,  and  when  the  bladder 
contracts,  part  of  the  urine  escapes  from  the  urethra,  part  is  forced  up  into 
the  sac.  An  opening  may  or  may  not  exist  at  the  umbilicus.  If  there  be 
no  exit  at  the  umbilicus,  the  valve-like  opening  between  the  urachus  and 
bladder  is  after  a  time  temporarily  overcome,  and  suddenly  there  escapes 
from  the  bladder  a  large  quantity  of  ammoniacal  urine  mixed  with  pus, 
the  urachal  tumor  at  once  disappearing.  Such  a  sac  will  fill  up  and  empty 
periodically. 


582  THE    UMBILICUS   AND    ITS   DISEASES. 

which  was  not  relieved  until  the  fistula  reopened.  The  discharge  was  so  offensive 
that  the  patient  could  not  mingle  with  his  friends.  Worster's  patient  also  de- 
veloped a  tumefaction  in  the  umbilical  region,  followed  by  the  escape  of  pus  and 
urine. 

The  opening  in  Weiser's  Case  3,  did  not  develop  at  the  umbilicus,  but  2  inches 
below  it.     Urine  only  escaped;  at  no  time  was  there  any  pus. 

When  the  infection  of  the  urachus  extends  up  to  the  umbilicus,  it  is  but  natural 
that  the  latter  should  be  secondarily  involved,  particularly  when  much  tension 
exists  in  the  sac. 

Constitutional  symptoms  have  not  been  at  all  prominent  in  these 
cases,  evidently  because  there  was  a  certain  amount  of  drainage  by  the  bladder, 
umbilicus,  or  both.  In  Hastings',  Lexer's,  and  Morgan's  cases  fever  was  present, 
and  in  Morgan's  case  there  was  vomiting  accompanied  by  diarrhea. 

The  carefully  recorded  case  reported  by  Hastings  in  1829-  (p.  589)  is  well  worth 
a  thorough  study.  This  case  clearly  shows  that,  notwithstanding  most  alarming 
symptoms,  such  as  convulsions,  the  patient  may  recover.  Savory's  patient,  a 
sickly  child  thirteen  months  old,  died;  in  this  case  the  inflammatory  process  had 
extended  to  the  abdomen,  as  indicated  by  the  adherent  omentum.  Ball's  eight- 
year-old  child  died  of  peritonitis. 

In  Xicaise's  (p.  597)  and  Roser's  (p.  598)  cases  the  patients  successfully  passed 
through  a  pregnancy  while  suffering  from  an  infected  urachal  cyst.  Roser's 
patient  miscarried  during  a  subsequent  pregnancy  four  years  later. 

The  urachal  cyst  varies  considerably  in  size.  It  is  attached  to  the 
bladder  below  and  to  the  umbilicus  above,  and  any  great  increase  in  size,  as  a  rule, 
will  be  in  its  central  portion.  In  Bramann's  case  the  tumor  resembled  a  long 
sausage.  In  Worster's  patient  it  was  recognized  as  a  large  cord,  two  inches  in 
diameter.  In  Freer 's  case,  when  the  patient  was  fourteen  years  old,  it  was  the 
size  of  an  apple,  but  when  she  came  under  observation,  at  fifty-four,  it  was  much 
larger.  In  Patel's  case  the  tumor  was  the  size  of  two  fists.  Vaughan's  patient 
had  a  pyriform  tumor  three  inches  long,  and  having  a  capacity  of  about  three 
ounces.  Schnellenbach's  tumor  was  the  size  of  a  head,  while  in  Timmerman's 
case  the  sac  contained  about  1500  c.c.  of  fluid. 

Urachal  cysts  communicating  with  the  bladder  can  hardly  reach  as  large  pro- 
portions as  some  of  those  that  have  no  external  opening.  In  Roser's  case,  however, 
notwithstanding  the  opening  into  the  bladder,  the  sac  contained  between  three  and 
four  liters  of  fluid. 

The  walls  of  the  sac  may  be  thin  or  thick,  depending  in  a  large  measure  upon 
the  amount  of  inflammatory  reaction.  In  Newman's  case  the  walls  were  thin; 
in  Bramann's  case  they  were  several  millimeters  thick,  and  in  Matthias'  case  they 
varied  from  2  to  20  mm.  in  thickness. 

The  interior  usually  consists  of  but  one  cavity.  The  inner  surface  may  be  per- 
fectly smooth,  or  lined  with  granulation  tissue.  On  histologic  examination  the 
inner  surface  may  have  a  lining  of  transitional  epithelium,  as  noted  in  Bramann's 
case,  or  of  one  layer  of  squamous  epithelium,  as  found  by  Schnellenbach.  In  the 
latter 's  case  the  underlying  stroma  showed  small-round-cell  infiltration. 

The  cyst  fluid  in  Patel's  case  was  pale  yellow.  In  the  greater  number  of  the 
cases  it  consisted  of  urine  and  pus.  The  urine  in  Newman's  and  in  Roser's  case 
was  very  ammoniacal.     In  Vaughan's  case  the  cavity  contained  laminated  clots. 


URACHAL    CAVITIES    AND    INFECTIONS.  583 

DIFFERENTIAL  DIAGNOSIS. 

The  history  of  cystitis,  coupled  with  the  development  of  a  tumor  just  above  the 
symphysis,  is  strong  presumptive  evidence  of  a  dilated  urachus,  particularly  if  the 
tumor  increases  in  size  when  the  patient  has  not  voided  for  several  hours,  or  if  it 
decreases  markedly  in  size  after  catheterization,  accompanied  simultaneously  by 
pressure  on  the  tumor.  There  are  some  cases,  however,  in  which  the  effort  to  void 
forces  a  large  part  of  the  urine  out  of  the  bladder  into  the  sac,  only  a  portion  escaping 
from  the  urethra.  In  such  cases  the  tumor  is  larger  after  the  bladder  has  been 
emptied. 

With  the  aid  of  the  cystoscope  the  diagnosis  becomes  more  easy.  In  Matthias' 
case,  for  example,  on  exploration  of  the  bladder  a  transverse  oval  opening  was  found 
near  the  top  of  the  anterior  blaclder-wall.  This  passed  into  a  funnel-shaped 
diverticulum,  which  extended  upward  toward  the  umbilicus. 

Occasionally  a  suppurating  dermoid  or  an  inflamed  appendix  ulcerates  through 
into  the  bladder.  When  the  dermoid  opens  into  the  bladder,  the  tumor  is  situated 
in  one  side  of  the  pelvis.  The  urachal  tumor,  on  the  other  hand,  is  in  the  mid-line, 
and  lies  in  the  anterior  abdominal  wall.  Furthermore,  in  the  case  of  a  dermoid 
cyst,  on  cystoscopic  examination  it  may  be  possible  to  see  a  tuft  of  hair  projecting 
from  it  into  the  bladder.  When  an  appendix  opens  into  the  bladder,  there  has 
usually  been  a  definite  history  of  appendicitis  and  the  discharge  passing  from  the 
bladder  has  a  distinctly  fecal  odor.  The  following  case  although  not  exactly 
germane  to  the  subject  has  several  points  in  common,  and  is  of  such  interest  that 
I  shall  briefly  report  it. 

In  May,  1907,  I  saw  a  very  interesting  case  of  extra-uterine  pregnancy,  in 
which,  long  after  the  death  of  the  fetus,  the  sac  opened  into  the  bladder.  The 
patient,  L.  S.,  colored,  aged  thirty-three  (Gyn.  No.  13806),  was  admitted  to  the 
Johns  Hopkins  Hospital  on  May  3,  1907.  For  the  previous  five  years  she  had  com- 
plained of  much  pain  in  the  lower  right  abdomen.  This  was  usually  dull,  and 
occasionally  accompanied  by  nausea.  Three  years  before  admission  she  was  sup- 
posed to  be  pregnant  and  to  have  proceeded  to  about  the  eighth  month.  Severe, 
labor-like  pains  lasting  five  minutes  suddenly  developed,  and  the  patient  passed 
blood  from  the  uterus.  Shortly  afterward  she  noticed  that  the  abdominal  girth 
was  diminishing,  and  that  a  hard,  tender  lump  was  present  in  the  right  lower  ab- 
domen. This  gradually  became  smaller.  She  gave  no  history  of  chills  or  of  fever, 
but  had  had  some  vomiting,  had  suffered  from  pain  from  time  to  time,  and  had  lost 
in  strength  and  in  weight. 

On  admission  the  right  lower  abdomen  was  distended  by  an  irregular  nodular 
mass,  which  on  palpation  gave  a  peculiar  feeling  of  crepitus.  On  pelvic  examination 
the  uterus  was  found  slightly  enlarged  and  lying  posteriorly.  On  the  right  side 
was  a  pelvic  mass  attached  to  the  side  of  the  uterus. 

On  catheterization  under  ether  a  large  amount  of  thick,  tenacious  urine  came  away, 
and  the  catheter  came  in  contact  with  a  substance  feeling  very  much  like  a  stone. 

Operation. — A  median  incision,  after  liberation  of  the  adherent  omentum,  dis- 
closed a  large,  irregular  mass  in  the  right  lower  abdomen.  The  large  and  small 
bowel  were  found  densely  adherent  to  the  sac.  The  small  bowel  was  dissected  free, 
but  its  coats  were  slightly  injured. 

The  sac  contained  a  large  number  of  fetal  bones  (Fig.  249) .     The  bladder  was 


584 


THE    UMBILICUS    AND    ITS    DISEASES. 


densely  adherent  to  the  mass,  and  after  it  had  been  freed,  an  opening  was  found  to 
exist  between  the  sac  and  the  bladder.  One  of  the  long  bones,  a  femur,  was  seen  pro- 
jecting from  the  sac  into  the 
bladder,  and  the  portion  ly- 
ing in  the  bladder  was  heav- 
ily coated  with  urinary  salts 
(Fig.  250) .  The  vesical  open- 
ing was  closed. 

In  the  cecum,  near  the 
ileocecal  valve,  long  bones 
projected  from  the  fetal  sac 
into  the  lumen  of  the  bowel.. 
There  was  a  second  open- 
ing into  the  large  bowel  six 
inches  above  the  ileocecal 
valve.  After  closing  the 
intestinal  openings  and  re- 
moving the  appendix,  which 
was  thickened  and  indu- 
rated, I  also  removed  a  par- 
ovarian cyst  from  the  right 
side.  The  abdomen  was 
then  drained.  The  patient 
made  a  good  recovery. 

In  such  a  case  as  this  the 
previous  history  pointed  to 
a  pregnancy.  Bimanual  ex- 
amination revealed  an  intra- 
abdominal tumor  situated 
on  one  side,  and  not  in  the 
mid-line.  Cystoscopic  ex- 
amination would  have  de- 
termined the  presence  of  a 
foreign  substance  projecting 
into  the  bladder. 

From  the  foregoing  it  is 
seen  that  urachal  tumors 
connected  with  the  bladder 
are  relatively  easy  to  diag- 
nose. 


Fig.  249. — Fetal  Bones  Removed  from  an  Old  Extra-uterine  Preg- 
nancy Sac. 

Oyii.  No.  13806.  The  bones  have  been  roughly  assembled.  They  are 
very  well  preserved.  'J'Ik-  ends  of  t  wo  long  bones  projected  into  the  lumen  of 
the  cecum  :i in  1  one  into  I  In-  cavity  of  the  bladder.  The  end  of  this  bone  is 
heavily  coated  with  phosphates.   This  is  particularly  well  shown  in  Fig.  250. 


TREATMENT. 
WJiere  a  marked  infec- 
tion is  present,  it  is  advis- 
able merely  to  open  up  and  drain  the  sac.     If  possible,  at  the  same  time  the  bladder 
should  be  separated  from  the  sac  and  the  vesical  opening  closed.     The  sac  is  then 
packed  and  allowed  to  contract  down. 


URACHAL    CAVITIES    AND    INFECTIONS. 


585 


If  there  is  little  danger  of  infection,  the  umbilicus  is  encircled  and  removed, 
together  with  the  sac,  and  the  bladder  opening  closed. 

The  vesical  symptoms  usually  disappear  as  soon  as  the  source  of  irritation — 
the  dilated  urachus — is  eliminated. 


EXISTENCE  OF  A  URACHAL  CAVITY  BETWEEN  THE  SYMPHYSIS  AND  UMBILICUS, 
AND  COMMUNICATING  WITH  THE  BLADDER  OR  UMBILICUS  OR  BOTH. 

Quite  a  number  of  the  cases  in  the  literature  were  not  sufficiently  definite  to 
warrant  citation;  only  those  that  clearly  illustrate  the  condition  have  been  selected. 

Cystitis  with  Tu  m  o  r 
Formation  in  the  Blad- 
der.— In  1882  Ball*  saw  a  boy 
eight  years  old  who  had  suffered  from 
incontinence  of  urine  at  night  from 
birth,  and  during  the  previous  six 
weeks  also  by  day.  In  March,  1882, 
the  urine  was  bloody  and  contained 
pus,  but  the  boy  improved,  although 
he  was  still  complaining  of  pain  in  the 
lower  abdomen.  When  he  next  came 
to  Ball,  in  January,  1883,  he  had  an 
umbilical  fistula,  which  he  stated  had 
appeared  three  weeks  previously  after 
rupture  of  an  abscess.  Since  that  time 
all  the  urine  had  passed  through  the 
navel.  The  urethra  was  very  small, 
but  later  a  moderate  amount  escaped 
by  this  passage  also. 

The  treatment  consisted  in  cauter- 
izing the  opening.  This  was  clone  three 
times.  The  parts  remained  healed  only 
for  a  short  time.  A  fourth  operation 
was  of  a  plastic  nature;  the  fistula  re- 
mained closed  for  two  months.  One 
month  later  the  boy  died  of  peritonitis. 

At  autopsy  the  urinary  organs  were 
removed  entire.  On  the  next  day  the 
cavities  were  first  injected  with  colored 

lard  through  an  opening  in  one  of  the  ureters.  A  minute  hole  about  13^  inches  below 
the  umbilicus  and  2}^  inches  above  the  fundus  of  the  bladder  was  found.  From  this 
urine  had  escaped  into  the  abdominal  cavity.  In  the  upper  abdomen  there  was 
abundant  evidence  of  a  recent  peritonitis.  The  omentum  was  adherent  to  the  an- 
terior abdominal  wall,  apparently  as  the  result  of  a  long  antecedent  inflammation. 
The  amount  of  fluid  in  the  abdominal  cavity  was  small,  but  there  was  an  abun- 
dance of  lymph  matting  the  abdominal  viscera  together. 

*  Ball,  C.  B. :  Case  of  Pervious  Urachus  with  Remarkable  Disease  of  Bladder.  Trans.  Acad. 
Med.  Ireland,  1883-84,  Dublin,  1884,  ii,  376.  This  case  is  probably  identical  with  that  referred 
to  by  Freer  in  1887.     Although  the  age  does  not  correspond,  the  findings  were  precisely  the  same. 


Fig.  250. — A  Phosphatic  Deposit  ox  the  End  of  a 
Long  Bone. 
Gyn.  No.  13S06.  One  end  of  this  bone  projected  into 
the  bladder  and  has  a  heavy  covering  of  urinary  phos- 
phates. This  is  clearly  evident  in  the  lower  part  of  the 
picture. 


586  THE    UMBILICUS    AND    ITS    DISEASES. 

The  ureters  and  pelves  of  the  kidneys  were  much  dilated.  The  bladder  was 
very  small  and  firm;  the  walls  were  much  thickened.  From  the  fundus  of  the 
bladder  to  the  umbilicus  extended  a  tongue-like  cavity,  23^  by  1%  inches.  This 
was  situated  between  the  peritoneal  covering  and  the  muscular  layers  of  the  an- 
terior abdominal  wall.  It  was  in  the  anterior  wall  of  this  cavity  that  the  fatal 
rupture  had  taken  place. 

During  the  separation  of  the  bladder  from  the  other  pelvic  contents  it  was  found 
that  the  viscus  was  surrounded  by  cicatricial  adhesions.  The  bladder-walls  were 
enormously  hypertrophied,  and  projecting  into  the  cavity  were  a  number  of  new- 
growths  which  resembled  the  columnse  carnese  of  the  heart.  Some  were  attached 
by  one  end  only  to  the  vesical  wall,  the  other  end  being  free  in  the  cavity;  others 
were  attached  at  both  ends,  but  were  free  along  the  sides,  so  that  a  probe  could  be 
passed  between  them  and  the  bladder-wall.  Microscopic  examination  showed  that 
they  were  composed  of  fibrous  tissue  with  a  covering  of  mucosa. 

The  bladder  was  divided  into  two  compartments  by  a  septum.  This  was 
attached  posteriorly  about  the  middle  of  the  trigonum.  Immediately  above  the 
septum  was  a  minute  opening  leading  off  into  the  cicatricial  tissue  in  front  of  the 
bladder.  There  had  evidently  been  an  extravasation  of  urine  which  had  become 
localized  as  the  result  of  an  inflammation. 

The  fundus  of  the  bladder  communicated  with  the  cavity  lying  between  it  and 
the  umbilicus  by  a  wide  opening.  The  cavity  contrasted  remarkably  with  the 
bladder  proper.  Its  walls  were  extremely  thin  and  the  inner  surface  smooth.  The 
openings  by  which  the  extravasation  had  taken  place  into  the  peritoneal  cavity 
were  two  in  number — one  a  small  aperture,  the  other  a  rent  apparently  of  recent 
origin. 

\Yhether  this  case  was  one  in  which  the  urachus  had  remained  patent  up  to  the 
umbilicus  and  in  which,  upon  supervention  of  bladder  obstruction,  suppuration  had 
occurred  at  the  umbilical  cicatrix,  leaving  a  fistulous  opening,  or  whether,  in  con- 
sequence of  an  extravasation  of  urine  in  the  neighborhood  of  the  fundus,  an  abscess 
cavity  had  been  formed  which  followed  the  track  of  the  obliterated  urachus,  are 
among  the  interesting  pathologic  features  of  the  case. 

An  Abscess  Between  the  Umbilicus  and  Symphysis 
Opening  at  the  Umbilicus. — On  August  7,  1821,  Bourgeois*  pre- 
sented to  the  Paris  Society  a  young  soldier,  aged  twenty,  who  had  at  the  lower  por- 
tion of  the  umbilical  cicatrix  a  granular  excrescence  the  size  of  a  small  lentil.  At  its 
summit  was  a  minute  cavity,  from  which  there  escaped,  drop  by  drop,  and  some- 
times in  a  jet,  a  fluid  which  resembled  urine.  The  patient  had  pain  in  the  anterior 
abdominal  wall  which  extended  from  the  pubes  to  the  umbilicus.  Several  times 
after  fatigue  the  discomfort  became  severe  and  it  was  necessary  to  apply  liniments. 
Later  he  had  an  attack  of  retention  of  urine  and  complained  of  a  feeling  of  insup- 
portable tension.  After  several  days  a  round  tumor  developed.  It  was  the  size 
of  an  almond,  and  was  red,  soft,  and  fluctuating.  When  the  patient  attempted 
to  urinate,  this  mass  became  tense.  He  was  brought  to  the  hospital  and  came  under 
the  care  of  Larrey,  who  incised  the  tumor.  The  skin  was  very  thin,  and  there 
escaped  a  large  quantity  of  serosanguineous  and  purulent  fluid  of  a  strongly  urinary 
odor,  which  suggested  a  communication  between  this  cavity  and  the  urinary  tract. 

*  Bourgeois:  Jour.  gen.  de  med.,  annee  1821,  lxxvi,  219. 


URACHAL    CAVITIES    AND    INFECTIONS.  587 

Tumor  Formation  Between  the  Umbilicus  and  Sym- 
physis Due  to  Remains  of  the  Urachus.  —  Bramann,*  in  1887, 
reported  a  case  from  von  Bergmann's  clinic.  The  patient  was  a  girl  of  twelve 
who  had  been  normal  until  her  ninth  year.  She  then  complained  of  pain  and  fre- 
quent micturition,  and  there  was  a  discharge  of  pus  and  a  little  blood  from  the  bladder. 
Two  years  later  the  urine  suddenly  came  through  the  umbilicus  and  continued  to 
pass  by  this  route,  although  her  physician  tried  to  close  the  opening  by  cauteriza- 
tion. The  urachus  was  dissected  out  and  the  bladder  opening  closed.  A  fistula 
followed,  and  this  still  persisted  up  to  the  time  that  the  case  was  reported.  When 
she  came  under  observation  a  granulation  the  size  of  a  pea  was  detected  at  the 
umbilicus;  in  the  center  of  this  was  a  depression  from  which  urine  escaped.  Be- 
hind the  abdominal  wall,  in  the  median  line,  and  below  the  umbilicus,  and  reaching 
to  the  symphysis,  was  a  long,  sausage-shaped  tumor,  which  was  soft  and  adherent 
to  the  umbilicus,  but  movable  low  down.  Rectal  examination  showed  that  the 
lower  end  passed  to  the  bladder.     The  urethra  was  normal. 

After  appropriate  treatment  for  the  cystitis  a  radical  operation  was  undertaken. 
The  fistulous  tract  was  dissected  out  as  far  as  the  bladder,  but  the  peritoneum  tore 
at  one  point  and  the  omentum  protruded.  It  was  wiped  off  and  replaced  and  the 
peritoneum  closed.  The  urachus  was  several  millimeters  thick,  dark  red,  yielding, 
and  lined  with  a  membrane  resembling  mucosa.  Here  and  there  it  was  apparently 
lined  with  granulation  tissue.  It  opened  directly  into  the  bladder.  Microscopic- 
examination  showed  that  the  canal  was  lined  with  transitional  epithelium,  next  to 
which  was  connective  tissue,  and  external  to  this  non-striped  muscle-fiber.  After 
operation  the  fistula  persisted. 

Escape  of  Urine  From  the  Umbilicus,  f  —  The  patient  was 
a  married  woman,  forty  years  of  age,  suffering  from  what  was  said  to  be  a  vesico- 
umbilical fistula.  This  patient  came  under  Freer's  care  while  he  was  resident 
surgeon  at  the  Ward's  Island  Hospital.  She  complained  of  a  chronic  purulent 
discharge  from  the  umbilicus,  as  a  result  of  which  she  had  become  so  exhausted  that 
she  was  scarcely  able  to  walk.  Freer  discovered  at  the  umbilicus  a  fistulous  open- 
ing. A  uterine  sound  was  introduced  and  glided  without  obstruction  downward 
almost  its  entire  length,  and  by  giving  it  a  lateral  motion,  Freer  found  that  it 
entered  a  cavity  which  had  a  breadth  of  almost  three  inches  in  its  widest  portion. 
On  removal  of  the  probe  pus  welled  up  from  the  opening,  and  when  pressure  was 
exercised  from  below  upward,  several  ounces  of  pus  escaped.  The  cavity  was 
washed  out  with  a  2  per  cent  carbolic-acid  solution,  and  it  was  not  until  the  dis- 
proportion between  the  amount  of  fluid  injected  and  that  which  returned  was 
noticed  that  the  true  nature  of  the  case  was  surmised.  This  was  afterward  proved 
by  the  injection  of  a  starchy  solution,  after  which  the  bladder  was  emptied  and  the 
iodin  test  applied  to  the  evacuated  fluid,  which  yielded  the  characteristic  appearance 
of  the  blue  iodid  of  starch.  The  patient  was  put  on  a  nourishing  diet,  and  after 
local  treatment  in  a  short  time  the  purulent  discharge  ceased  and  the  fistula  closed 
spontaneously.  She  stated  that  a  similar  result  had  been  achieved  at  other  hos- 
pitals on  previous  occasions,  but  that  the  fistula,  after  remaining  closed  for  a  short 
time,  would  then  reopen,  with  a  repetition  of  the  above  symptoms.     Sometimes, 

*  Bramann,  F.:    Zwei  Falle  von  offenem  Urachus  bei  Erwachsenen.     Arch.  f.  klin.  Chir., 
1887,  xxxvi,  996. 

t  Freer,  J.  A. :  Abnormalities  of  the  Urachus.     Annals  of  Surg.,  1887,  v,  107. 


588  THE    UMBILICUS    AND    ITS    DISEASES. 

when  she  strained,  urine  would  be  forced  up  through  the  opening,  but  this  was  so 
infrequent  that  she  considered  it  of  slight  importance.  She  had  no  difficulty  in 
passing  the  urine  by  the  natural  channel. 

Cyst  of  the  Urachus  Communicating  With  the  Blad- 
der. —  Freer*  cites  a  case  reported  by  Helmuth  in  The  Homeopathic  Journal 
of  Obstetrics,  1884,  vi,  24.  This  patient  was  a  married  woman,  fifty-four  years  of 
age,  of  small  stature  and  slight  build.  At  the  age  of  seven  years  her  abdomen 
appeared  to  be  enlarged;  at  fourteen  a  tumDr  the  size  of  an  apple  appeared 
at  the  umbilicus  and  burst,  sending  forth  a  stream  of  fluid  with  considerable 
force.  Her  menses  ceased  at  the  age  of  forty-four,  after  which  her  abdomen  be- 
came enlarged  and  sensitive  to  pressure.  Incontinence  of  urine  was  a  source  of 
great  discomfort  to  her,  especially  at  night,  when  the  dripping  would  awaken  her. 
Helmuth  withdrew  with  the  aspirator  about  a  quart  of  viscid,  dark  fluid,  which 
showed  "inflammatory"  and  pus  corpuscles.  Subsequently,  when  performing 
an  ovariotomy,  after  dividing  the  peritoneum,  he  says:  "I  came  upon  a  substance 
which  puzzled  me.  It  looked  something  like  a  cyst- wall,  but  was  so  densely 
adherent  to  the  abdomen  at  the  umbilicus  that  it  was  impossible  to  separate  the  ad- 
hesions. Laterally,  on  each  side  of  the  incision,  the  substance  disappeared.  After 
vainly  endeavoring  to  push  this  sufficiently  aside,  I  determined  to  incise  it,  which  I 
did.  A  gush  of  fluid  followed,  and  for  a  moment  I  believed  I  had  opened  the  sac. 
Upon  introducing  my  finger  into  the  incision  I  soon  discovered  that  the  canal  com- 
municated directly  with  the  bladder.  I  then  forcibly  drew  this  emptied  sac  aside, 
and  without  difficulty  removed  the  [ovarian]  tumor.  From  some  experience  in 
suprapubic  lithotomy  I  determined  to  bring  the  wall  of  the  bladder-cyst  together 
with  carbolized  catgut,  which  I  did.  A  self-retaining  catheter  was  placed  in  the 
bladder  and  the  woman  put  to  bed.  The  patient  died  on  the  evening  of  the  fifth 
daj'  from  peritonitis."  Helmuth  says  the  patulous  and  cystic  urachus,  leading  from 
the  fundus  of  the  bladder  to  the  umbilicus,  accounts  for  many  peculiar  symptoms 
detailed  by  the  patient. 

That  the  bursting  of  the  umbilicus  in  early  life,  when  the  "water  spouted  up  to 
the  ceiling,"  was  due  to  the  rupture  of  the  external  wall  of  the  cyst  was  proved  by 
the  cicatrix,  smooth  and  white,  which  occupied  the  site  of  the  umbilicus. 

Persistence  of  the  Urachus  in  Adult  Women.  —  Gar- 
riguest  did  an  autopsy  on  a  woman  aged  forty-five.  He  found  that,  owing  to  the 
presence  of  a  dilated  urachus,  the  bladder  extended  as  far  as  the  navel,  where  it 
was  closed.  The  patient  had  been  operated  on  for  myoma  ten  days  before  and 
had  died  of  nephritis.  The  urachus  was  noted  at  the  time  of  operation.  The 
bladder  extended  to  the  umbilicus  and  lay  between  the  aponeurosis  of  the  abdominal 
muscles  and  the  transversalis  fascia  on  one  side,  and  the  peritoneum  on  the  other. 

An  Infected  Urachus  Communicating  With  the  Blad- 
der and  U  m  b  i  1  i  c  u  s  .  —  Graft  cites  the  case  of  a  man  aged  twenty.  At 
twelve  years  of  age  he  had  inflammation  of  the  diaphragm,  and  four  years  later 
gastric  fever.  A  year  and  a  half  before  Graf  saw  him  he  had  noticed  that  the  urine 
escaped  from  the  umbilicus.  The  tissue  in  the  vicinity  of  the  umbilicus  was  some- 
what swollen,  reddened,  and  painful.  He  did  not  know  whether  he  had  had  fever. 
On  admission  he  was  found  to  be  pale  and  anemic.     He  had  a  frequent  desire  to 

*  Freer,  J.  A.:   Op.  cit.  t  Garrigues,  H.  J.:  Med.  Record,  New  York,  1899,  lvi,  720. 

%  Graf,  Fritz:  Urachusfisteln  und  ihre  Behandlung.     Inaug.  Diss.,  Berlin,  1896,  16. 


URACHAL    CAVITIES    AND    INFECTIONS.  589 

urinate.  He  had  pain  in  the  abdomen,  and  from  time  to  time  fluid  escaped  from 
the  umbilicus.  Passing  downward  in  the  mid-line  from  the  umbilicus  was  a  hard 
cord,  as  wide  as  two  fingers,  which  could  be  felt  going  toward  the  bladder.  The 
symptoms  indicated  a  vesical  catarrh,  and  there  was  a  gonorrheal  inflammation  of 
the  urethra.  After  lavage  of  the  bladder,  carried  out  for  three  weeks,  the  patient 
was  better.     The  pus  had  stopped  escaping  from  the  umbilicus. 

Operation. — The  umbilicus  was  cut  around  and  the  cord  dissected  out.  The 
peritoneum  was  opened  over  an  area  of  10  cm.  It  was  walled  off  with  iodoform 
gauze;  the  bladder  opening,  which  was  about  0.5  cm.  in  diameter,  was  closed. 
The  patient  made  a  good  recovery. 

The  inner  surface  of  the  fistula  consisted  of  granular  tissue.  In  places  it  had 
grown  into  the  lumen.  Only  near  the  umbilical  opening  had  the  cavity  an  epithelial 
lining,  the  cells  being  of  the  squamous  type. 

A  Singular  Case  of  Ischuria.*  —  "On  the  9th  of  April,  1814, 
M.  H.,  aged  twenty-three,  was  admitted  an  in-patient  of  the  Worcester  Infirmary. 
She  represented  herself  as  having  been  particularly  healthy.  Within  the  last  week 
she  had  been  exposed  to  cold,  whilst  the  catamenia  were  flowing  abundantly. 
For  the  first  day  or  two  she  appeared  to  suffer  only  from  feverish  symptoms;  soon 
afterward,  however,  the  secretion  of  urine  became  very  deficient,  and  she  had 
difficulty  in  passing  it. 

"On  the  evening  of  her  admission  she  became  much  worse,  and  complained 
specially  of  pain  and  tenderness  over  the  whole  of  the  lower  part  of  the  abdomen 
and  in  the  loins.  There  was  vomiting  and  a  disposition  to  convulsions.  The 
lower  part  of  the  abdomen  was  much  distended.  A  catheter  was  introduced,  and 
ten  ounces  of  urine  were  drawn  off,  after  which  the  pain  was  relieved.  She  was 
ordered  to  take  a  scruple  of  cathartic  extract  immediately,  and  one  drachm  of 
sulphate  of  magnesia,  dissolved  in  camphor  mixture,  three  times  a  day. 

"The  next  morning  the  bowels  had  not  been  moved.  She  was  afflicted  with 
severe  headache,  as  well  as  the  abdominal  pains.  She  had  passed  no  water,  and 
was  delirious  during  the  night. 

"She  was  cupped  on  the  back,  and  had  a  blister  applied,  and  took  cathartic 
mixture  every  four  hours  till  the  bowels  moved  freely;  after  which  she  wTent  into  a 
warm  bath. 

"The  symptoms  remained  for  several  days  very  much  in  the  same  state.  De- 
lirium usually  came  on  during  the  night.  No  urine  was  passed  by  the  natural 
effort,  but  about  three  ounces  were  drawn  off  by  the  catheter  in  the  course  of 
twenty-four  hours.  She  very  frequently  vomited,  and  suffered  much  from  pain, 
tenderness,  and  tension  of  the  lower  part  of  the  abdomen. 

"On  the  evening  of  the  17th  insensibility  came  on,  for  which  a  blister  was  ap- 
plied to. the  back  of  the  neck;  the  pulse  was  sixty.     An  active  aperient  was  given. 

"On  the  19th  no  improvement  had  taken  place,  for  the  vomiting  was  incessant, 
and  the  pain  in  the  abdomen  and  back  was  more  severe.  Pulse,  80.  She  was  bled 
three  days  in  succession,  with  some  alleviation  of  the  pain,  but  the  abdomen  became 
generally  enlarged  and  very  tender;  there  also  ceased  to  be  any  urine  drawn  from 
the  bladder  by  the  catheter.  This  continued  to  be  the  case  for  five  days.  The 
bowels  were  open.     She  took  saline  diuretics  without  avail. 

*  Hastings,  Charles:  London  Med.  and  Phys.  Jour.,  1829,  X.  S.,  vi,  515. 


590  THE    UMBILICUS   AND    ITS    DISEASES. 

"On  the  25th  there  was  much  vomiting,  pain,  and  distention  of  the  abdomen, 
but  she  passed  a  little  urine.     Pulse,  80.     She  was  bled  to  eight  ounces. 

"On  the  27th  a  bloody  discharge  appeared  at  the  umbilicus,  after  which  the  ab- 
dominal pain  and  tension  were  relieved.  She  also  passed  some  urine  by  the  urethra. 
The  vomiting  was,  however,  worse  than  it  had  previously  been. 

"The  bloody  discharge  from  the  umbilicus  and  the  other  symptoms  continued 
very  much  the  same  till  the  2d  of  May,  when  there  was  a  discharge,  of  urinous  ap- 
pearance and  smell,  from  the  umbilicus.  She  had  passed  no  urine  by  the  urethra 
for  three  days.  The  head  was  very  painful,  the  pupils  dilated;  pulse,  56;  bowels 
costive.  Some  leeches  were  applied  to  the  temples,  and  a  blister  to  the  back  of  the 
neck;  a  brisk  purge  was  administered.  The  catheter  was  introduced,  but  no  urine 
found  in  the  bladder. 

"The  discharge  of  urine  from  the  umbilicus  continued  till  the  5th,  when  the 
catamenia  appeared,  but  quickly  vanished.  The  abdomen  became  less  tense  and 
tender;  there  was  not  so  much  vomiting ;  the  bowels  were  open. 

"  From  the  7th  to  the  9th  there  was  no  discharge  of  urine  from  the  umbilicus, 
nor  was  there  any  passed  by  the  urethra;  as  a  consequence,  the  abdomen  became 
much  distended  and  severe  pain  followed,  with  vomiting.  The  tension  was  most 
remarkable  at  the  umbilicus,  forming  a  circumscribed  tumor. 

"On  the  10th,  in  the  morning,  six  ounces  of  urine  were  drawn  off  by  the  catheter; 
and  in  an  hour  after,  two  quarts  of  urine  of  the  same  appearance  gushed  from  the 
umbilicus.  This  was  followed  by  much  relief  of  the  abdominal  pains.  The  dis- 
charge of  urine  from  the  umbilicus  continued  for  three  days  and  was  accompanied 
with  great  improvement  of  the  general  symptoms. 

"The  amendment,  however,  did  not  last,  for  the  discharge  from  the  umbilicus 
again  ceased,  and  for  three  days  the  vomiting,  the  headache,  the  abdominal  tension 
and  pain  returned  with  their  former  severity. 

"On  the  17th  the  catheter  was  introduced  into  the  bladder  and  no  urine  was 
found.  In  an  hour  after  this,  two  quarts  of  urine  passed  from  the  umbilicus,  and 
soon  afterward  great  relief  was  experienced. 

"From  this  time  to  the  25th  there  was  little  variation;  but  the  young  woman 
suffered  during  that  interval  very  much  from  vomiting  and  daily  passed  urine  from 
the  umbilicus.  The  catheter  was  passed  every  day,  and  no  urine  was  found,  but 
the  bladder  contracted  strongly  on  the  instrument;  sometimes,  immediately  after 
the  catheter  was  removed,  a  discharge  of  urine  would  take  place  by  the  umbilicus, 
and  once  as  much  as  three  quarts  were  thus  passed. 

"On  the  26th,  for  the  first  time  after  many  days,  four  ounces  of  urine  were 
drawn  from  the  bladder.  Each  succeeding  day  this  quantity  was  now  increased 
and  the  quantity  passed  by  the  umbilicus  was  diminished.  There  was  also 
a  general  improvement  of  the  symptoms,  with  the  exception  of  vomiting;  this 
continued  obstinate.  All  this  time  the  medicine  that  she  took  was  confined 
chiefly  to  the  class  of  purgatives;  blisters  were  also  applied  to  the  neck  and  epi- 
gastrium. 

"The  bladder  was  regularly  emptied  every  day  by  the  catheter  for  more  than  a 
month  after  this  date,  during  which  time  the  abdominal  pain  and  vomiting  sub- 
sided, and  there  was  no  discharge  from  the  umbilicus.  Early  in  July  she  began  to 
pass  some  urine,  and  the  power  over  the  bladder  was  gradually  restored.     She  was 


URACHAL    CAVITIES    AND    INFECTIONS.  591 

discharged  in  the  middle  of  July  in  tolerable  health,  but  still  often  complained  of 
pain  in  the  pelvic  region.     She  menstruated. 

"Observations. — This  curious  case  of  ischuria  is  well  worthy  of  consideration. 
The  remarkable  sympathy  observable  between  the  brain,  the  stomach,  the  kidneys, 
is  common  to  all  cases  of  this  description,  and  is  so  obvious  as  not  to  require  any 
further  comment. 

"The  very  remarkable  feature  in  the  case  is  the  occurrence  of  the  urinary  dis- 
charge from  the  umbilicus  many  days  after  the  ischuria  had  been  noticed.  Such 
instances,  although  rare,  are  not  without  parallel  in  the  annals  of  medicine.  Schenck 
relates  two  instances  of  this  kind.  In  the  one,  a  male,  the  urine  was  discharged  in 
consequence  of  an  obstruction  at  the  neck  of  the  bladder,  'tanquam  mictione  ex 
umbilico,'  for  many  months  without  any  detriment  to  health.  In  the  other,  a 
female,  and  more  resembling  the  one  now  related,  'cum  suppressa  per  multas  dies 
fuisset  urina,  tandem  per  umbilicum  urinam  profuclit.'  (Schenck,  Obs.,  Lib.  iii, 
deUrina,  p.  489.) 

"The  interesting  question  is  to  determine  in  what  manner  the  urine  is  conveyed 
to  the  umbilicus  in  these  instances.  The  urachus  offers  itself  as  a  means  by  which 
the  discharge  may  be  determined  to  that  part,  and  it  seems  probable  that,  in  the 
case  of  mechanical  obstruction  related  by  Schenck  at  the  neck  of  the  bladder,  a 
channel  of  communication  was  formed  by  the  urachus  between  the  bladder  and  the 
umbilicus.  But,  in  the  case  we  now  remark  upon,  there  had  been  no  urine  secreted 
into  the  bladder  long  before  its  appearance  at  the  umbilicus,  nor  was  there  for  some 
time  after;  and  the  first  discharge  from  the  umbilicus  was  not  of  a  urinary  but 
bloody  nature.  We  must  consequently,  I  think,  regard  the  urinary  discharge  in 
this  instance  as  vicarious,  and  as  proceeding  probably  from  the  peritoneal  surface. 
This  view  seems  confirmed  by  the  great  abdominal  distention,  which  took  place 
for  some  time  previous  to  the  discharge  from  the  umbilicus,  when  it  was  invariably 
found,  from  introducing  the  catheter,  that  the  bladder  was  empty,  and  that  it  con- 
tracted on  the  instrument. 

"Some  cases  of  this  description  have  been  placed  upon  record  by  eminent  men 
worthy  of  great  credit.  There  is  none,  perhaps,  more  deserving  of  attention  than 
that  by  Platerus,  which  is  thus  related  by  the  renowned  Sennertus:  'Puellae 
cuidam  annos  natae  tredecim,  cum  aliquando  copiose  minxisset,  urinam  subito 
suppressam  esse,  atque  tunc  aquam  serosam  ex  aure  dextra  adeo  affatim  coepisset 
effluere,  ut  una  vice  mensurae  duae  ssepe  emanarint,  idque  dies  aliquot.'  He  then 
adds  that,  on  diuretics  being  administered,  the  urine  was  passed  freely  from  the 
bladder,  and  the  discharge  from  the  ear  ceased;  but  as  soon  as  the  diuretics  were 
discontinued,  the  discharge  again  took  place  from  the  ear,  but  was  altogether  re- 
moved by  general  terebinthinate  remedies,  and  local  repellents  to  the  ear.  The 
health  did  not  suffer.     (Sennerti  Opera,  Lib.  iii,  p.  8,  §  ii,  cap.  ix.) 

"In  our  case  it  was  evident  that  much  inflammatory  action  was  going  on  in  the 
pelvic  viscera  previous  to  and  during  the  discharge  of  urine  from  the  umbilicus; 
and  there  was  a  considerable  sympathy  of  the  general  health  with  the  local  inflam- 
matory action. 

"I  may  further  add,  as  a  notice  to  this  case,  that  the  young  woman  was  again 
admitted  into  the  infirmary  in  May,  1827,  for  paralysis  of  the  lower  extremities, 
from  which  she  recovered  by  appropriate  remedies.  The  urine  for  a  time  was  drawn 
off  by  the  catheter,  but  there  was  no  return  of  the  former  disease." 


592  THE    UMBILICUS   AND    ITS    DISEASES. 

Umbilical  Urinary  Fistula  in  a  Middle-aged  Man.*  — 
(  lase  IV. — The  patient  was  a  middle-aged  man,  who  complained  of  a  tender  and 
irritable  bladder  when  he  was  jolted.  A  fixed  pain  developed  just  above  the  pubes, 
and  he  noticed  an  increased  desire  to  urinate.  A  hardness  could  be  detected  above 
the  pubes.  Suddenly  the  patient  felt  something  give  way,  and  pus  passed  from  the 
bladder  through  the  urethra.  He  was  greatly  relieved.  Recovery  followed,  and 
three  years  later  he  was  well.  Hind  thought  that  in  this  case  there  had  been  an 
abscess  of  the  patent  portion  of  a  urachus. 

Cyst  of  the  Urachus.  —  In  discussing  Douglas's  paper  Illf  said  that 
recently  he  had  removed  a  cyst  of  the  urachus  as  large  as  two  fists  without  difficulty. 
The  patient  was  a  woman  who  had  some  prolapse  of  the  anterior  vaginal  wall,  and 
when  she  attempted  to  pass  her  urine,  some  of  it  passed  into  the  cyst  and  some 
escaped  through  the  urethra.  This  did  not  have  the  effect,  however,  of  producing 
an  inflammatory  condition  about  the  cyst.  The  condition  was  annoying  to  her, 
because  she  had  to  pass  her  urine  in  installments,  as  it  were. 

The  operation  consisted  in  removal  of  the  cyst  and  ligation  of  that  portion  of  the 
duct  which  entered  the  bladder.  As  he  was  closing  the  wound  he  said  to  himself: 
''This  is  a  dangerous  procedure,  and  it  is  likely  that  this  ligature  will  not  destroy 
the  epithelium  and  that  the  bladder  will  open  in  a  short  time."  Some  infiltration 
of  urine  taking  place,  he  removed  the  ligature,  cut  the  duct  very  short,  turned  in 
the  edges,  and  closed  it  over,  as  a  surgeon  would  do  with  an  appendix  stump. 

Cystitis  Followed  by  the  Opening  Up  of  a  Partially 
Patent  Urachus,  Producing  a  Urinary  Fistula  at  the 
Umbilicus.  —  Lexer!  reports  the  case  of  a  poorly  developed  young  man, 
twenty  years  old,  who  said  that  previously  he  had  never  noticed  anything  abnormal 
at  the  umbilicus.  A  year  and  a  half  before  admission,  after  several  weeks  of  diffi- 
culty in  urinating,  the  urine  being  cloudy,  he  had  pain  in  the  region  of  the  umbilicus, 
the  tissue  in  the  vicinity  of  the  navel  swelled  up  and  became  red.  Shortly  after 
a  quantity  of  purulent  fluid  escaped  from  the  umbilicus.  The  bladder  discomfort 
became  more  severe;  he  frequently  had  fever  and  chills  and  became  thinner.  In 
addition  to  a  marked  degree  of  cystitis  there  was  blennorrhea  of  the  urethra.  Gon- 
ococci  were  isolated  from  the  urethral  discharge.  On  account  of  the  swelling  and 
inflammatory  infiltration,  the  fistula  at  the  umbilicus  was  not  visible,  but  the 
umbilical  funnel  filled  up  when  pressure  was  made  by  the  patient,  and  when  pres- 
sure on  the  bladder  was  exerted  the  umbilical  cavity  filled  up  with  pus  and  foul- 
smelling  urine. 

The  cystitis  was  first  treated.  In  the  washing-out  of  the  bladder  purulent 
flocculi  escaped  from  the  umbilicus,  so  that  finally  the  entire  fluid  escaped  from  the 
umbilical  opening.  Nevertheless,  it  was  impossible  to  introduce  a  sound  farther 
than  2  cm.  into  the  fistula.  By  the  third  Aveek  the  patient  had  improved  greatly. 
He  had  no  further  fever,  the  urine  was  passed  without  pain,  he  looked  well,  and  the 
escape  of  pus  from  the  umbilical  fistula  had  ceased.  Urine,  however,  continued  to 
escape  from  the  umbilicus  as  soon  as  the  bladder  contained  an  appreciable  amount  of 
fluid. 

On  account  of  the  gonococcus  infection  it  was  felt  wiser  not  to  leave  in  a  perma- 

*  Hind,  \V.:  Diseases  of  the  Urachus  and  Umbilicus.     Brit.  Med.  Jour.,  1902,  ii,  242. 

t  111,  Edward  J.:  Amer.  Jour.  Obst.,  1897,  xxxvi,  568. 

X  Lexer,  E.:   Ueber  die  Behandlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  1893,  lvii,  73. 


URACHAL    CAVITIES    AND    INFECTIONS.  593 

nent  catheter.  The  abdominal  walls  were  not  so  painful  on  pressure,  and  one  could 
now  make  out  a  hard  cord,  the  thickness  of  a  finger,  in  the  mid-line,  extending  from 
the  umbilicus  to  the  bladder.  After  the  cystitis  had  subsided,  closure  of  the  umbilical 
fistula  was  considered.  As  it  was  impossible  to  introduce  a  sound  far,  an  excision 
of  the  upper  portion  of  the  cord  was  undertaken.  The  umbilicus  was  dissected 
free,  and  the  fistulous  tract  about  2  cm.  below  this  point  was  opened.  Here  there 
was  a  small  lumen  into  which  a  sound  could  be  introduced  without  difficulty  and 
carried  toward  the  bladder  region.  The  farther  dissection  of  the  cord  was  easily 
accomplished  without  injury  to  the  peritoneum.  Midway  between  the  umbilicus 
and  symphysis,  however,  it  was  impossible  to  avoid  entering  the  abdominal  cavity. 
From  the  opening  in  the  peritoneum  one  could  see  the  relation  of  the  bladder  very 
well.  This  cord  spread  out  and  passed  without  any  definite  margin  gradually 
into  the  upper  portion  of  the  bladder,  just  as  is  the  case  in  the  embryo.  Care  was 
taken  not  to  injure  the  general  peritoneal  cavity.  The  urachus  was  freed  to  the 
point  where  it  entered  the  bladder.  It  was  then  cut  across  transversely,  so  that 
the  entire  tract  from  the  umbilicus  to  the  bladder  was  excised.  A  funnel-like 
opening,  1.5  cm.  wide,  was  left  in  the  bladder.  Examination  of  the  inner  surface 
of  the  bladder  showed  that  this  organ  was  a  long,  thick-walled  tube,  similar  to  that 
noted  in  Bramann's  case.  The  opening  in  the  bladder  was  closed,  and  a  drain  laid 
into  the  incision.     The  wound  had  healed  completely  in  four  weeks. 

At  the  end  of  two  and  a  half  years  there  was  no  evidence  of  any  fistula,  and  the 
patient  was  completely  cured,  the  only  discomfort  being  frequent  urination. 

A  Case  of  Patent  Urachus  Over  One  Inch  in  Diameter 
Forming  a  Tubular  Prolongation  of  the  Bladder. — 
Marshall*  reports  the  case  of  a  woman,  aged  forty-three,  who  had  complete  pro- 
cidentia. On  opening  the  abdomen  to  suspend  the  uterus,  and  while  making  a  short 
incision  midway  between  the  pubes  and  umbilicus,  he  found  the  subperitoneal  fat 
very  abundant.  On  dividing  this  he  could  see  what  appeared  to  be  peritoneum. 
A  nick  having  been  made  into  it,  a  pair  of  scissors  was  passed  upward  and  then 
downward  to  enlarge  the  incision. 

On  lifting  the  retroflexed  uterus  up  to  the  abdominal  opening  and  thus  com- 
pressing the  bladder,  Marshall  noted  an  escape  of  some  clear  fluid  into  the  lower 
part  of  the  wound.  This  aroused  his  suspicions.  A  bougie  introduced  into  the 
bladder  through  the  urethra  entered  the  abdominal  incision  through  a  large  open- 
ing. What  was  at  first  thought  to  be  peritoneum  was  in  reality  the  anterior  wall 
of  a  patent  urachus.  The  first  cut  upward  had  slit  through  the  upper  blind  end  in 
the  peritoneum  into  the  abdominal  cavity.  The  downward  cut  had  opened  the 
peritoneum  and  both  walls  of  the  urachus. 

The  urachal  opening  was  V/i  inches  in  diameter  and  formed  a  large  opening  in 
the  conic-shaped  bladder.  The  bladder  was  closed  with  a  double  layer  of  continu- 
ous catgut  sutures  and  a  catheter  was  kept  in  for  one  week.  The  patient  made 
a  good  recovery. 

Suppuration  of  the  Persistent  Urachus  With  Rupture 
into  the  Bladder  and  the  Abdominal  Wall.f  —  In  November, 
1901,  a  forty-eight-year-old  man  came  to  Mikulicz's  clinic.   He  had  had  a  gonococcal 

*  Marshall:  Jour,  of  Obst.  and  Gyn.  of  the  Brit.  Empire,  1907,  xi,  259. 

t  Matthias,  F. :   Vereiterung  des  persistierenden  Urachus  mit  Durchbruch  in  die  Blase  und 
in  die  Bauchdecken.     Beitrage  z.  khn.  Chir.;  herausg.  von  Paul  Bruns,  Tubingen,  190-1,  xlii,  339. 
39 


594  THE    UMBILICUS    AND    ITS    DISEASES. 

infection  ten  years  before,  which  had  not  been  promptly  treated.  For  the  last 
few  years  he  had  had  an  abundant  discharge  from  the  urethra.  Apart  from  this 
the  patient  had  been  well.  Six  months  before  admission,  he  began  to  have  a 
pressure  in  the  lower  abdominal  region  and  suffered  from  a  general  feeling  of 
malaise.  The  urine  was  cloudy  and  contained  whitish  threads  and  flocculi.  There 
was  a  cramp-like,  sticking  pain  in  the  urethra.  During  the  three  months  following 
this  the  patient  lost  weight  and  the  urine  was  cloudy.  Two  months  later  there  was 
again  pain  in  the  lower  abdomen,  and  a  tumor  could  be  felt  above  the  top  of  the 
bladder.  Mikulicz  found  a  firm,  ill-defined  tumor  lying  below  the  umbilicus. 
This  occupied  the  mid-line  and  extended  a  little  more  to  the  right.  It  commenced 
three  fingerbreadths  below  the  umbilicus,  and  ended  5  cm.  above  the  symphysis. 
There  was  a  cord  passing  from  the  tumor  to  the  umbilicus.  The  umbilicus  itself 
appeared  normal. ,  Mikulicz  thought  that  he  was  dealing  with  an  abscess  of  the 
abdominal  wall,  and  one  that  communicated  with  the  bladder,  and  that  its  origin 
was  due  to  the  extension  of  a  cystitis  by  way  of  a  persistent  urachus.  Bladder 
irrigations  were  employed.  When  there  was  a  large  quantity  of  pus  in  the  urine, 
the  tumor  became  smaller  and  the  patient  felt  better.  The  reverse  was  the  case 
when  the  urine  contained  but  little  pus.  The  difference  in  the  size  of  the  tumor  was 
manifested  in  its  transverse  diameter.  When  a  large  amount  of  pus  escaped  in  the 
urine  and  the  tumor  had  diminished  to  half  its  volume,  a  cystoscopic  examination 
was  made.  In  the  anterior  bladder-wall,  in  the  neighborhood  of  the  top  of  the 
bladder  and  in  the  mid-line,  was  a  transverse  oval  opening  passing  into  a  funnel- 
shaped  diverticulum.  The  walls  of  this  could  be  seen  for  some  distance,  but  the 
point  ended  in  darkness. 

Operation. — A  median  incision  was  made.  The  skin  was  dissected  free  from 
the  tumor,  which  was  covered  with  thick  and  edematous  fascia,  and  on  the  left 
side  the  peritoneal  cavity  was  opened.  From  this  point  the  tumor  was  separated 
from  the  abdominal  wall,  and  in  the  lower  angle  of  the  incision  the  bladder  was 
recognized  by  means  of  a  metal  catheter  which  had  been  introduced  from  below.  The 
tumor  sat  on  the  top  of  the  bladder,  and  on  the  right  and  on  the  left,  between  the 
tumor  and  bladder,  was  a  loop  of  small  bowel  which  was  separated  without  injury. 
The  tumor  was  the  size  of  a  billiard  ball,  and  sat  as  a  cap  on  the  top  of  the  bladder. 
The  muscular  covering  of  the  bladder  extended  over  on  it,  particularly  on  the  pos- 
terior surface.  The  peritoneal  cavity  was  well  walled  off  and  the  tumor  opened. 
Its  walls  were  12  mm.  thick,  and  the  cavity  was  the  size  of  a  walnut.  From  it 
escaped  an  old  clot  mixed  with  pus.  An  attempt  was  made,  by  filling  the  bladder  with 
300  c.c.  of  salt  solution,  to  find  a  communication  with  the  abscess  cavity.  In  this 
the  operator  was  unsuccessful ;  no  fluid  escaped,  but  a  sound  could  be  passed  from 
the  cavity  into  the  bladder.  The  tumor  was  separated  from  the  bladder.  The  small 
opening  in  the  bladder-wall  was  closed  with  catgut,  and  the  muscularis,  which  formed 
two  flaps  over  the  tumor,  was  brought  together.  A  retention  catheter  was  intro- 
duced into  the  bladder  and  kept  in  place  for  ten  days.  The  urine  then  came  away 
spontaneously,  and  the  pus  disappeared  almost  completely.  The  extirpated  tumor 
was  the  size  of  an  apple  and  irregularly  round.  Its  walls  varied  from  2  to  20  mm. 
in  thickness,  and  there  were  irregular  dilatations  in  the  interior.  It  consisted  of 
striated,  dense  connective  tissue.  Here  and  there  were  citron-yellow  portions, 
undoubtedly  fatty  tissue.  The  inner  surface  of  the  sac,  apart  from  dilatations, 
was  uneven;   no  mucosa  was  visible. 


URACHAL    CAVITIES    AND    INFECTIONS.  595 

Microscopic  Examination. — Sections  showed  that  the  wall  was  made  up  of 
smooth  muscle-fibers,  connective  tissue,  and  an  inner  zone  consisting  of  old  con- 
nective tissue  containing  many  round-cells  and  small  blood-vessels.  There  were 
hemorrhages,  and  here  and  there  the  tissue  was  necrotic.  There  was  no  evidence 
of  epithelium.  Mikulicz  found  a  small  opening  in  the  wall  of  the  tumor.  This 
was  lined  with  epithelium.  It  could  be  traced  for  a  distance  of  2  mm.  in  serial 
sections,  and  had  a  breadth  of  1  mm.  The  epithelium  lining  the  canal  was  several 
layers  thick;  only  in  a  few  places  did  it  consist  of  a  single  layer. 

In  conclusion  Mikulicz  said  that  very  probably  the  normal  dilatation  of  the 
opening  of  the  urachus  in  the  bladder,  being  funnel-shaped,  had  allowed  the  cystitis 
to  extend  to  the  urachus,  and  through  breaking  of  the  wall  there  had  resulted 
abscess  formation  in  the  musculature  of  the  bladder-wall  and  of  the  abdominal 
wall  to  the  umbilicus.  Since  the  abscess  originally  lay  within  the  bladder  mus- 
culature, its  rupture  into  the  interior  of  the  bladder  near  the  actual  opening  of  the 
urachus  was  not  exceptional. 

[There  is  no  doubt  in  this  case  that  there  was  an  abscess  between  the  bladder 
and  the  umbilicus.  It  was  probably  of  urachal  origin,  but  Matthias's  description 
is  not  particularly  clear. — T.  S.  C] 

Escape  of  a  Calculus  From  the  Umbilicus.*  —  This  case 
had  been  reported  by  Gennaro  in  1890.  After  a  mucopurulent  discharge  from 
the  umbilicus  had  lasted  several  days,  a  calculus  escaped  from  the  umbilical  open- 
ing. It  consisted  of  urate  of  soda,  phosphate  of  lime,  and  magnesia.  The  urachus 
was  a  diverticulum  of  the  bladder.  Gennaro  thought  that  the  calculus  was  due  to 
fermentation  of  the  stagnant  ammoniacal  urine. 

A  Case  of  Dilated  Urachus  Accidentally  Opened 
During  an  Abdominal  Section  for  Peritonitis.  Re- 
covery.f  —  A  boy,  aged  five,  was  brought  to  the  Children's  Hospital,  Brighton, 
on  February  18,  1896.  There  was  a  history  of  vomiting  and  diarrhea  for  two  days. 
On  admission  he  was  suffering  with  severe  abdominal  pain,  but  there  was  no  marked 
tenderness.  His  temperature  was  102°  F.  The  next  day  he  was  much  worse,  and 
lay  on  his  left  side,  with  his  thighs  fully  flexed.  The  distention,  tenderness,  and 
pain  were  more  severe.  There  was  no  localized  swelling.  His  diarrhea  was  almost 
constant.  His  temperature  was  103.6°  F.,  his  pulse,  108.  In  the  next  five  days 
there  was  some  improvement  in  his  general  condition.  The  abdomen  was  still 
distended,  but  the  vomiting  and  diarrhea  were  improved.  On  the  ninth  day,  in 
the  region  of  the  bladder  and  extending  nearly  to  the  umbilicus,  there  could  be 
made  out  a  certain  amount  of  resistance  that  was  fairly  sharply  defined.  Micturi- 
tion was  frequent,  but  there  was  no  dribbling.  On  the  suspicion  that  the  swelling 
might  be  the  bladder,  a  catheter  was  passed,  but  only  about  half  an  ounce  of  urine 
was  drawn  off.  This  did  not  affect  the  size  or  position  of  the  hypogastric  fulness. 
On  February  27th  the  general  condition  was  better,  except  that  he  was  passing  a 
large  quantity  of  mucus  by  bowel.  The  distention  and  hypogastric  fulness  were 
less  marked.  On  the  evening  of  the  next  day,  twelve  days  after  the  first  symp- 
toms, the  boy  was  much  worse,  his  vomiting  had  returned,  and  the  distention  was 

*  Monod,  Jean:  Des  fistules  urinaires  ombilicales  dues  a.  la  persistance  de  l'ouraque.  These 
de  Paris,  1899  (obs.  47),  168. 

t  Morgan,  G.:  The  Lancet,  1896,  ii,  1154. 


596  THE    UMBILICUS    AND    ITS    DISEASES. 

very  severe.     His  temperature  was  103°  F.  and  his  condition  so  critical  that  it  was 
decided  to  operate  at  once. 

An  incision  was  made  extending  from  the  umbilicus  to  a  point  near  the  pubes. 
The  deeper  abdominal  layers  were  divided  carefully  over  a  director.  An  incision 
was  made  into  what  was  taken  for  the  subperitoneal  fat  and  peritoneum,  and  there 
was  a  gush  of  about  one  ounce  of  clear  urine.  The  wound  was  at  once  clamped  and 
a  catheter  was  passed.  The  bladder  was  found  to  be  quite  empty  and  lying  in  the 
pelvis,  but  the  catheter  could  be  passed  up  into  the  wound  in  the  cyst  where  the 
clamp  was.  After  carefully  dissecting  around  the  cyst,  Morgan  opened  the  ab- 
dominal cavity  and  found  signs  of  recent  peritonitis,  with  flakes  of  lymph,  but  no 
pus.  The  abdominal  cavity  was  flushed  with  hot  water,  and  the  intestines  were 
carefully  sponged.  The  boy  was  too  ill  to  have  a  prolonged  examination  or  have 
the  mass  dissected  out,  but  it  was  certain  that  the  cyst  was  in  the  mid-line,  running 
up  to  the  umbilicus  and  communicating  with  the  bladder.  After  the  bladder  and 
cyst  had  been  washed  out  with  boric  acid  solution,  the  wound  in  the  bladder  was 
closed  with  a  double  row  of  silk  sutures,  the  stitches  not  penetrating  to  the  mucous 
membrane.  The  abdominal  wall  was  also  carefully  closed.  On  the  following  day 
the  boy  was  much  better,  but  on  the  fourth  day  pus  began  to  well  up  from  the  suture 
line.  Three  stitches  were  taken  out  and  the  pus  cavity  was  irrigated.  For  ten 
days  after  this  there  was  some  escape  of  urine  from  the  abdominal  wound,  but 
this  became  less  and  less,  and  the  boy's  general  condition  improved.  Twenty- 
six  days  after  operation  the  wound  was  closed  and  the  boy  was  quite  well. 

A  Rare  Variety  of  Cyst  of  the  Urinary  Bladder, 
Probably  Arising  From  the  Urachus,  Cured  by  Opera- 
tion.*—  A.  M'V.,  a  miner,  aged  thirty-nine,  was  admitted  to  the  Glasgow 
Royal  Infirmary  on  October  21,  1895.  He  complained  of  severe  pain  in  the  hypo- 
gastric region.  This  had  commenced  four  days  before,  and  had  continued  ever  since. 
Coincident  with  the  onset  of  the  pain  he  found  that  he  was  unable  to  micturate, 
and  his  doctor  had  to  pass  a  catheter.  When  the  urine  was  drawn  off,  it  con- 
tained a  large  quantity  of  blood.  Vomiting  came  on  soon  after  the  onset  of  the 
pain  and  was  followed  by  attacks  of  diarrhea. 

On  admission  he  was  suffering  considerable  pain,  had  an  anxious  expression  and 
walked  with  difficulty.  The  skin  over  the  region  of  the  bladder  was  red  and  blis- 
tered from  the  use  of  hot  fomentations  and  applications  of  mustard.  The  abdomen 
was  considerably  swollen,  very  tense  over  the  region  of  the  bladder,  and  from  the 
umbilicus  to  the  pubes  it  was  absolutely  dull  on  percussion.  After  admission  a 
catheter  was  passed  and  20  ounces  of  urine,  containing  a  large  quantity  of  blood, 
were  drawn  off.  This  gave  the  patient  considerable  relief,  but  even  after  the  blad- 
der had  been  completely  emptied,  the  dulness  in  the  hypogastric  region  did  not 
disappear.  From  the  1st  until  the  8th  of  November  the  patient's  condition  steadily 
improved,  and  at  the  latter  date  he  was  able  to  pass  his  urine  without  difficulty. 
On  examination  the  abdomen  still  showed  a  considerable  amount  of  swelling  in  the 
hypogastric  region.  The  swelling  in  appearance  greatly  resembled  a  distended 
bladder. 

Operation. — A  free  incision  was  made  in  the  mid-line,  midway  between  the  pubes 

*  Newman,  D.:  Throe  Renal  Cases,  a  Case  of  Cyst  of  the  Urachus,  and  a  Case  of  Strangu- 
lated Hernia,  Treated  in  the  Surgical  Wards  of  the  Glasgow  Royal  Infirmary.  Glasgow  Med. 
Jour.,  1896,  xlvi,  20. 


URACHAL    CAVITIES    AND    INFECTIONS.  597 

and  the  umbilicus.  On  incision  into  the  transversalis  fascia,  a  large  quantity  of 
gelatinous  fluid  escaped  which  had  a  strongly  ammoniacal  odor.  The  cyst-wall 
was  thin  and  smooth,  and  its  anterior  wall  was  not  covered  with  peritoneum.  The 
cyst  extended  from  the  apex  of  the  bladder  to  the  umbilicus.  After  evacuation  of 
the  contents  the  cyst  was  washed  out  with  carbolic  acid  solution,  and  a  drainage- 
tube  inserted.  In  the  evening  the  dressing  was  found  to  be  soiled  with  urine  which 
had  a  strongly  ammoniacal  odor. 

On  November  16th  the  greater  part  of  the  urine  was  passing  through  the  ab- 
dominal wound  and  a  retention  catheter  was  now  introduced  into  the  urethra. 
Notwithstanding  this  the  urine  continued  to  escape  from  the  wound,  and  not  until 
December  16th  did  the  cyst  become  completely  obliterated  and  the  wound  in  the 
abdomen  close.  On  careful  inquiry  into  the  history  of  the  patient  it  was  found 
that  he  had  noticed  a  swelling  in  the  hypogastric  region  as  long  as  he  could 
remember,  but  until  this  occasion  it  had  never  given  him  any  trouble. 

Probably  a  Partially  Patent  Urachus  with  Infec- 
tion.* —  This  patient  was  observed  by  Chopart.  She  was  pregnant,  and  had 
suffered  from  retention  of  urine  for  some  time.  The  abdomen  became  tender  and 
painful.  Fluctuation  was  felt,  and  was  specially  marked  in  the  region  of  the 
umbilicus.  An  incision  was  made  between  the  right  rectus  muscle  and  the  umbili- 
cus, and  much  pus  escaped.  On  the  following  clay  the  bed  and  the  apparel  of  the 
patient  were  soaked  with  urine.  This  escaped  for  some  time  by  the  umbilicus 
until,  after  repeated  catheterization,  the  urine  commenced  to  pass  through  the 
urethra  and  the  umbilicus  closed. 

Dilatation  of  the  Urachus;  Communication  with 
the  Bladder.  —  Patel'sf  patient  was  a  child  three  years  of  age  who,  from 
birth,  had  incontinence  of  urine  both  day  and  night.  The  urine  did  not  escape  drop 
by  drop,  but  at  frequent  intervals  and  involuntarily.     There  were  no  malformations. 

Below  the  umbilicus  was  a  voluminous  tumefaction,  fusiform,  and  prominent 
in  its  central  portion.  In  its  middle  portion  it  was  the  size  of  two  fists.  It  was 
exactly  in  the  median  line;  above  it  reached  the  umbilicus,  and  below  passed  into 
the  pelvis,  although  its  termination  could  not  be  felt.  It  was  movable.  Cathe- 
terization yielded  a  small  glass  of  clear  urine.  There  was  evidently  a  tumor  lying 
behind  the  abdominal  walls,  adherent  to  the  umbilicus,  and  clinically  independent 
of  the  bladder. 

A  median  incision  was  made  below  the  umbilicus.  The  tumor  was  found  ad- 
herent to  the  umbilicus.  Half  a  liter  of  pale-yellow  fluid  escaped,  which  contained 
large  quantities  of  albumin.  The  sac  was  lined  with  an  irregularly  wrinkled  muscu- 
lar layer.  Above  the  finger  impinged  on  the  umbilicus.  The  inferior  end  was  very 
narrow  and  was  dilated  with  difficulty.  It  led  to  a  small  circular  cavity  in  which 
the  vesical  trigonum  was  recognized.  Removal  of  the  diverticulum  was  not  under- 
taken on  account  of  the  size  of  the  tumor  and  of  its  probable  adhesion  to  the  peri- 
toneum, and  on  account  of  the  patient's  age.  The  walls  of  the  sac  were  sutured 
much  in  the  way  that  cavities  resulting  from  removal  of  hydatids  of  the  liver  are 
obliterated.     The  walls  were  brought  together  and  a  catheter  was  left  in  the  blad- 

*  Xicaise:  Ombilic.  Diet,  encycloped.  des  sci.  med.,  Paris,  1881,  2.  ser.,  xv,  140. 

|  Patel:  Malformation  congenitale  de  1'ouraque.  Dilatation  kystique  de  la  partie  interieure 
de  1'ouraque  demeure  en  communication  avec  la  vessie;  incontinence  d'urine  symptornatique. 
Capitonnage  de  la  poche.     Rev.  mens,  des  maladies  de  l'enfance,  Paris,  1904,  xxii,  77. 


598 


THE    UMBILICUS    AND    ITS    DISEASES. 


der.     During  the  five  days  that  the  catheter  remained  in  place  there  was  some  dis- 
charge from  the  abdominal  wall.     When  the  child  left  the  hospital,  the  abdomen 
was  soft.     The  bladder  was  large  enough  and  the  child  urinated  about  every  three 
hours.     There  was  no  incontinence.     Recovery  was  permanent. 
This  case  was  also  reported  by  Gabriel  Renard.* 

The  Diagnosis  and  Treatment  of  a  Case  of  Patent 
Urachus. f  —  The  patient  was  a  woman  twenty-five  years  of  age.  Six  months 
previously  she  had  begun  to  have  pain  in  the  umbilical  region.  Two  weeks  later  a 
swelling  had  appeared  at  the  umbilicus.  This  had  ruptured,  and  since  then  pus 
had  been  discharging,  except  during  occasional  intervals  of  a  week.     A  probe  was 

passed  through  the  umbilicus  into  the 
bladder,  and  the  end  emerged  at  the 
external  urinary  meatus. 

The  urachus  was  opened  on  a  direc- 
tor about  two  inches  above  the  symphy- 
sis. It  showed  a  dilatation  in  the  mid- 
dle, with  a  constriction  above,  and 
below,  where  it  connected  with  the 
bladder.  The  actual  cautery  was  used 
to  destroy  about  one  inch  of  the  lower 
portion  of  the  urachus.  The  portion 
above  was  packed,  a  piece  of  iodoform 
gauze  being  passed  through  the  fistula 
to  the  umbilicus.  The  bladder  was 
accidentally  opened,  but  at  once  closed 
with  catgut.  The  patient  made  a  good 
recovery. 

Urachal  Cyst  Communi- 
cating with  the  Bladder. 
— Robinson+  says:  " I  worked  several 
years  in  the  dissecting  room,  paying 
special  attention  to  visceral  and  pelvic 
anatomy,  but  did  not  see  any  urachal 
cyst  in  but  one  autopsy  (Fig.  251)."  In 
this  case  the  urachus  was  dilated,  form- 
ing a  fusiform  tumor.  It  opened  into 
the  bladder  and  extended  upward  as  far  as  the  umbilicus.  .  .  .  "I  understand 
from  veterinarians  that  the  horse  is  one  of  the  most  typical  animals  to  show  urachal 
cysts,  and  that  quite  late  in  horse  fetal  life  the  urachus  is  found  often  quite  a  dis- 
tance above  the  bladder." 

A  Urachal  Cyst  Communicating  With  the  Bladder.  — 
In  Roser's  §  case  the  urachal  cyst  had  a  small  opening  into  the  bladder  (Fig.  252) . 
When  the  patient  wished  to  void,  the  contraction  of  the  bladder  muscles  forced  the 

*  Etenard,  Gabriel:  Sur  un  kyste  de  l'ouraque.     These  de  Lyon,  1905,  No.  89. 
fReid,  \Y.  L.:   Glasgow  Hosp.  Reports,  1899,  ii,  76. 
%  Robinson,  F.  Byron:  Annals  of  Surg.,  1891,  xiv,  336. 

§  Roser,  W '.:  Ueber  Operation  der  Urachuscysten.  Langenbeck's  Arch.  f.  klin.  Chir.,  1877, 
xx,  47:;. 


Fig.  251. — A  Dilated  Urachus  Communicating  With 
the  Bladder.  (After  F.  Byron  Robinson.) 
The  urachus  (6)  is  patent  from  the  bladder  (a)  almost 
to  the  umbilicus.  It  is  markedly  dilated,  and  its  cavity 
communicates  directly  with  the  bladder.  It  resembles  a 
secondary  bladder. 


URACHAL    CAVITIES    AND    INFECTIONS. 


599 


urine  into  the  cyst  more  easily  than  through  the  urethra.  The  cyst,  therefore, 
became  more  and  more  distended,  until  three  or  four  liters  of  urine  accumulated. 
When  it  was  desired  to  empty  the  bladder,  a  catheter  had  to  be  introduced  into  it 
and  the  cyst  was  then  pressed  upon.  In  order  to  keep  the  patient  free  from  trouble 
catheterization  several  times  a  day  was  necessary. 

The  patient  had  what  appeared  to  be  a  greatly  distended  bladder  when  she  was 
three  months  pregnant.  A  puncture  was  made  in  the  linea  alba  above,  and  a  large 
amount  of  urine  removed.  The  pregnancy  went  to  term.  Four  years  later  she 
had  a  similar  attack  when  she  was  again  pregnant.  The  old  cyst  had  refilled.  It 
was  tapped  from  above,  and  the  patient  miscarried.  The  cyst  again  filled,  and 
operation  became  necessary.  The  urine  was  ammoniacal,  owing  to  stasis  in  the 
sac.    There  was  foul  urine  in  the  cyst,  which  at  that  time  had  reached  the  umbilicus. 

An  extraperitoneal  opening,  about  3  cm.  long,  was  made  in  the  mid-line,  and  two 
chambers  full  of  stinking  ammoniacal  puru- 
lent fluid  escaped.  There  was  temporary 
relief.  A  retention  catheter  failed  to  bring 
about  closure  of  the  bladder,  and  when  last 
seen,  the  patient  still  had  the  urachal  cyst 
opening  into  the  bladder. 

Polypus  of  the  Urinary  Blad- 
der with  the  Development  of 
a  Urinary  Fistula  at  the  Um- 
bilicus. — ■  Savory's*  patient  was  a  male, 
thirteen  months  old  and  sickly.  Immedi- 
ately beneath  and  partly  surrounding  the 
umbilicus  was  a  firm,  tense  swelling,  two  or 
three  inches  in  diameter.  Its  limits  were  not 
well  defined.  It  was  very  tender,  and  pain 
was  increased  by  attempts  to  void.  The  urine 
merely  dribbled  away.  The  child  had  been 
ill  eight  weeks.  The  first  thing  noticed  was 
that  micturition  caused  pain  in  the  lower  ab- 
domen, followed  by  an  almost  constant  desire  to  void 
rupted  temporarily  and  then  started  again. 

The  umbilical  induration  was  incised  and  pus  escaped;  later  urine  appeared, 
and  nearly  all  came  this  way- 

Autopsy.  —  On  section  of  the  abdomen  an  abscess  was  found  between  the 
posterior  surface  of  the  abdominal  parietes  and  the  peritoneum  and  extending 
from  the  umbilicus  almost  to  the  symphysis.  The  omentum  was  adherent  to 
the  abdominal  wall.  The  growth  in  the  bladder  stretched  across  behind  the  ure- 
teral orifices,  which  were  dilated.  This  mass  was  attached  at  each  side,  but  was 
free  in  the  center,  and  could  block  the  urethra.  It  was  a  polyp.  It  was  impossible 
to  find  the  opening  between  the  bladder  and  the  abscess  by  which  the  urine  escaped 
from  the  umbilicus. 

A    Partially    Patent    Urachus.t  —  Simon  reports  the  case  of  a 

*  Savory,  W.  S.:  Med.  Times,  London,  1852,  N.  S.,  v,  106. 

t  Simon,  Charles:   Quels  sont  les  phenomenes  et  le  traitement  des  fistules  urinaires  ombili- 
cales?     These  de  Paris,  1843,  No.  SO  (obs.  12),  26. 


Fig.  252. — Urachal  Cyst.  (Redrawn  by  August 
Horn  after  W.  Roser.) 
The  bladder  itself  looks  normal,  except  that 
at  the  upper  part  anteriorly  there  is  a  small  open- 
ing which  communicates  with  a  large  cyst  extend- 
ing as  high  as  the  umbilicus. 


The  stream  was  often  inter- 


600  THE    UMBILICUS    AND    ITS    DISEASES. 

patient  of  Portal,  a  man  forty-five  years  of  age,  who  died  shortly  after  a  fall  on  the 
abdomen  resulting  in  a  severe  injur}'  to  the  bladder.  Some  time  after  the  accident 
he  had  noticed  that  the  urine  was  escaping  at  the  umbilicus.  Portal  says:  "On 
opening  the  bod}'  I  found  a  tube  which  extended  from  the  umbilicus  to  the  blad- 
der. This  was  cone-shaped.  Its  diameter  toward  the  umbilicus  was  ^4  inch  and 
1^2  inches  at  the  bladder.  The  thickness  was  unequal.  The  volume  of  the  blad- 
der did  not  exceed  that  of  a  small  apple." 

An  Infected  Urachal  Cyst  Communicating  With  the 
Bladder.*  —  This  patient,  a  man  sixty-six  years  of  age,  came  under  Trendel- 
enburg's observation  on  July  3,  1887.  For  a  year  or  more  he  had  had  frequent 
urination.  The  urine  was  cloudy,  and  often  much  pressure  was  necessary  to  start 
it.  Six  months  before  he  had  noticed  a  swelling  in  the  lower  abdomen,  above  the 
symphysis.  For  three  or  four  days  he  had  had  pain  in  this  region,  and  soon  after 
a  spontaneous  opening  had  appeared  at  the  umbilicus  from  which  a  purulent  fluid 
had  escaped.     Recently  he  had  become  weaker. 

On  admission  to  the  hospital  he  showed,  in  the  hypogastric  region,  a  marked 
swelling  about  the  size  of  a  head.  This  began  just  above  the  symphysis  and  reached 
to  the  umbilicus.  Rectal  examination  revealed  an  enlarged  prostate,  especially  on 
the  right,  and  above  this  a  distended  bladder.  A  very  fine  sound  was  passed  from 
the  umbilicus  and  entered  into  a  large  cavity.  The  fluid  from  the  umbilicus  showed 
round-cells  undergoing  fatty  change.  After  catheterization  with  the  removal  of 
1500  c.c.  of  cloudy  urine  the  swelling  to  a  large  extent  disappeared,  but  there  per- 
sisted a  long  tumor  reaching  from  the  umbilicus  to  the  symphysis. 

Operation. — An  incision  was  made  between  the  umbilicus  and  the  symphysis. 
Immediately  behind  the  fascia  was  a  sac  containing  about  a  liter  of  urine  mixed  with 
pus.  A  piece  of  the  wall  was  removed,  and  the  wound  closed  with  drainage.  A 
purulent  fluid  continued  to  escape  from  the  sac.  Microscopic  examination  of  the 
wall  showed  it  to  be  lined  with  one  layer  of  squamous  epithelium  resembling  that 
of  the  bladder.  There  was  no  muscle  in  the  wall.  The  connective  tissue  con- 
tained many  round-cells. 

A  Dilated  Urachus  Communicating  With  the  Blad- 
der .  f  —  The  patient  was  a  very  frail  woman,  weighing  probably  85  pounds. 
At  labor  she  had  had  a  bad  tear  and  developed  a  fever,  from  100°  to  101.5°  F.,  for 
nearly  six  weeks.  In  the  following  spring  she  entered  the  hospital  for  operation, 
but  later  developed  pain  and  swelling  in  the  right  side. 

A  median  incision,  2^  inches  long,  was  made.  The  peritoneum  was  exposed 
and  cut,  but  the  bladder  was  opened.  The  patient  had  just  voided  before  the  opera- 
tion. The  wound  was  closed,  but  the  operator,  in  attempting  to  enter  the  peri- 
toneum, got  into  the  same  cavity  again.  It  proved  to  be  an  accessory  bladder — 
really  a  dilated  urachus — and  contained  l}/£  to  2  pints  of  urine.  A  catheter  intro- 
duced into  the  urethra  could  be  passed  into  this  cavity.  It  was  closed  and  the 
patient  recovered. 

Escape  of  Urine  From  the  Umbilicus.  —  UnterbergerJ  re- 
porter! the  case  of  a  woman,  twenty-three  years  of  age.     She  was  supposed  to  have 

Schnellenbach:    [Jeber  die  (Jrachuscysten.     Inaug.  Diss.,  Bonn,  1888. 
f  Timmerman,  C.  F.:  Trans.  Med.  Soc.  State  of  New  York,  1904,  331. 

tTJnterberger:  Retroversio-flexio  uteri  gravidi  partialis  incarcerata.  Urachus-fistel. 
Monatssohr.  f.  Geb.  u.  Gyn.,  1900,  xi,  657. 


URACHAL    CAVITIES    AND    INFECTIONS.  601 

had  an  ovarian  cyst  that  had  ruptured  through  the  umbilicus,  and  for  three  weeks 
clear  fluid  had  continued  to  escape  from  the  navel. 

The  trouble  had  begun  with  pain  in  the  lower  abdomen.  This  had  become  so 
severe  that  the  patient  had  been  forced  to  remain  in  bed  and  local  applications 
had  been  applied.     Urination  and  defecation  at  this  time  were  normal. 

The  patient  had  fever  and  gradually  became  weaker.  One  month  before  her 
admission  to  the  hospital  urinary  disturbances  developed,  and  after  a  time  the  urine 
commenced  to  escape  through  the  umbilicus  and  the  pain  disappeared.  Pus  some- 
times escaped  from  the  umbilicus  with  the  urine. 

For  fourteen  days  before  the  patient  entered  the  hospital  no  urine  had  been 
passed  from  the  urethra.  The  umbilical  opening  had  the  caliber  of  a  hair,  and  was 
surrounded  by  a  small  red  zone.  The  abdominal  walls  were  somewhat  infiltrated. 
A  catheter  passed  into  the  bladder  entered  for  its  entire  length  and  about  2000  c.c. 
of  urine  mixed  with  pus  were  removed.  The  uterus,  which  contained  a  pregnancy, 
was  retroverted  and  partially  incarcerated.  No  operation  was  performed,  but 
Unterberger  regarded  the  case  as  one  of  patent  urachus. 

A  Dilated  and  Infected  Urachus  Communicating 
With  the  Bladder  and  Umbilicus.*  —  A.  W.,  white,  male,  aged 
forty,  was  admitted  to  the  Georgetown  University  Hospital,  June  21,  1904.  When 
twenty  years  old  he  had  gonorrhea,  from  which  he  made  a  good  recovery.  His 
present  trouble  began  when  he  was  seventeen  years  of  age,  with  pain  in  the  supra- 
pubic region  extending  to  the  umbilicus.  There  was  induration  and  tenderness  of 
the  parts  on  pressure.  These  symptoms  grew  worse;  poultices  were  applied,  and 
two  weeks  later  an  opening  appeared  at  the  umbilicus  through  which  was  discharged 
a  moderate  amount  of  pus.  From  this  time  the  fistula  remained  patulous  almost 
constantly,  with  a  discharge  of  pus  and  urine.  Occasionally  it  would  close — never 
longer  than  for  two  days,  during  which  time  there  would  be  considerable  pain, 
especially  on  urination.  When  the  opening  closed,  the  area  around  and  below  the 
navel  would  become  inflamed,  and  when  it  was  reestablished,  spontaneously  or  by 
the  patient,  there  would  be  immediate  relief  from  pain  and  the  escape  of  a  large 
quantity  of  dark,  offensive-smelling  fluid.  The  odor  was  worse  after  the  fistula  had 
been  closed  a  day  or  two  than  when  it  was  discharging  freely,  but  at  all  times  it 
was  offensive,  to  a  great  extent  barring  the  patient  from  the  society  of  his  friends. 
The  discharge  had  always  been  most  profuse  during  urination,  and  in  the  morning, 
when  the  patient  would  begin  to  move  about,  but  there  was  at  all  times  enough  to 
keep  his  clothing  soiled.  At  thirty-four  years  of  age  he  had  an  attack  of  pain  in  the 
region  of  the  right  kidney,  with  nausea,  vomiting,  and  elevation  of  temperature, 
and  he  had  to  keep  to  his  bed  for  three  weeks.  Since  then  he  had  had  other  attacks 
of  less  severity,  usually  beginning  with  pain  in  the  loin  and  extending  to  the  tes- 
ticle, sometimes  accompanied  by  vomiting  and  the  passage  of  blood  through  the 
urethra.     The  attacks  had  always  been  most  severe  after  exertion. 

Examination  showed  a  large,  robust,  well-nourished  man,  with  good  color  and 
apparently  in  excellent  health.  At  the  umbilicus  was  a  flat  area  of  scar  tissue  of  a 
bluish  color,  containing  a  small  opening  through  which  a  probe  could  be  passed 

*  Vaughan,  George  T. :  Patent  Urachus.  Review  of  the  Cases  Reported.  Operation  on  a 
Case  Complicated  with  Stones  in  the  Kidneys.  A  Note  on  Tumors  and  Cysts  of  the  Urachus. 
Trans.  Amer.  Surg.  Assoc,  1905,  xxiii,  273. 


602  THE    UMBILICUS    AND     ITS    DISEASES. 

downward  and  slightly  backward  for  a  distance  of  three  and  one-half  inches  into 
a  pouch  which  lay  in  front  of  the  bladder. 

The  urine  from  the  bladder  contained  urates  and  epithelial  cells.  A  diagnosis  of 
patent  urachus  with  dilatation  into  a  pouch  and  infection  of  its  contents  was  made, 
and  operation  was  advised. 

Operation  (June  25,  1904). — The  bladder  was  distended  with  water  through 
the  urethra,  and  a  grooved  director  was  passed  through  the  umbilical  fistula  to  the 
bottom.  The  cavity  was  opened,  and  a  considerable  amount  of  bloody  pus,  with 
an  offensive  urinary  odor,  was  evacuated.  The  sac  was  pyriform  in  shape,  with 
the  small  end  above:  it  lay  in  front  of  the  peritoneum,  and  above  and  in  front 
of  the  bladder,  with  which  it  communicated  through  a  very  small  opening.  The 
sac  was  about  three  inches  in  length,  and  had  a  capacity  of  about  three  ounces; 
it  contained  many  laminated  clots  and  resembled  very  much  a  small  urinary  blad- 
der, the  walls  containing  muscular  and  fibrous  tissue  and  being  lined  with  mucous 
membrane.  The  sac  was  carefully  dissected  out,  the  peritoneum  being  opened  in 
two  places  accidentally,  and  the  walls  were  brought  together.  Recovery  was  with- 
out incident  except  for  the  high  temperature  that  occurred  on  the  day  after  opera- 
tion (107°  F.  in  the  axilla),  and  he  was  well  three  weeks  after  the  operation. 

On  August  13,  1904,  just  a  month  after  leaving  the  hospital,  the  patient  had  a 
severe  attack  of  renal  colic  on  the  right  side,  with  chills,  vomiting,  blood}^  urine, 
dehrium,  and  swelling  of  the  face  and  extremities.  His  pulse  was  140,  the  tempera- 
ture 104°  F.  On  August  21st  the  right  kidney  was  incised,  and  a  round  stone,  half 
an  inch  in  diameter,  was  removed.  After  this  the  patient  had  no  further  trouble 
until  February,  1905,  when  he  had  an  attack  of  renal  colic  on  the  left  side,  with  the 
passage  of  several  small,  pea-sized  calculi  from  the  bladder.  A  month  later  he  had 
another  attack,  which  was  much  more  severe  and  was  complicated  with  almost 
complete  suppression  of  urine  for  forty-eight  hours,  delirium,  chills,  and  a  tem- 
perature of  106°  F.  On  May  1,  1905,  the  left  kidney  was  incised  and  two  stones 
were  removed.  Up  to  June  27,  1905,  the  patient  had  had  no  further  trouble  with 
his  bladder,  but  had  had  an  attack  of  appendicitis  which  he  managed  to  pass  through 
without  operation. 

Under  date  of  May  12,  1915,  Dr.  Vaughan  writes:  "After  an  operation  on  both 
kidneys  for  stone  the  patient  got  along  pretty  well  until  December  6,  1906,  when  I 
had  to  operate  on  the  left  kidney  again,  removing  a  large  oval  stone.  Patient  re- 
covered, but  had  trouble  again  during  the  summer  of  1914  (during  my  absence), 
and  Dr.  Fowler  removed  stones  from  the  right  kidney.  He  is  in  pretty  good  con- 
dition now,  but  evidently  has  stones,  probably  in  both  kidneys.  Since  June  25, 
1904,  patient  has  had  five  operations — excision  of  urachus  and  two  operations  on 
each  kidney.'" 

Suppuration  of  a  Urachal  Cyst.  —  In  Weiser's*  Case  3  the  pa- 
tient was  a  man  aged  seventy-three,  who  had  always  been  well  except  for  an  attack 
of  orchitis  four  months  before  the  present  sickness.  For  six  months  he  had  suffered 
with  pain  and  soreness  in  the  abdomen,  but  had  noticed  no  tumor.  Two  weeks 
before  Weiser's  visit  the  abdominal  wall  had  opened  spontaneously  two  inches  be- 
low the  umbilicus,  and  discharged  urine.  There  had  never  been  any  pus.  When 
the  patient  was  lying  down  quietly,  the  urine  did  not  escape,  but  as  soon  as  he  as- 
sumed an  upright  position,  there  was  a  constant  discharge.  The  old  gentleman 
*  Weiser,  W.  R.:  Annals  of  Surg.,  1906,  xliv,  529. 


URACHAL    CAVITIES    AND    INFECTIONS. 


603 


OOTteo  LINE 
REPRESENTS 
UVACHUS  *-* 
CYST  WALLS 


appeared  perfectly  well  aside  from  this  urinary  sinus,  which  in  caliber  was  about 

the  size  of  a  pencil,  and  entered  immediately  into  a  large  sac,  the  lower  limit 

of  which  Weiser  could  not  reach  with  an  eight- 
inch  probe. 

Weiser  entered  the  peritoneal  cavity  above  the 

sinus,  and  found  the  sac  anterior  to  the  parietal 

peritoneum.     The  sac  extended  to  within  one  inch 

of  the  umbilicus,  above  which  the  urachus  was  not 

patulous  (Fig.  253),  and  downward  into  the  pelvis. 

It  was  intimately  connected  with  the  bladder  at  the 

point  of  urachal  attachment,  and  was  densely  ad- 
herent to  the  posterior  bladder-wall  as  well  as  to 

the  intestines,  the  greater  part  of  the  sac  being  made 

up  of  abdominal  viscera.     After  freeing  the  anterior 

wall  of  the  cyst  sufficiently,  he  made  a  plastic  closure 

of  the  original  point  of  rupture  through  the  abdom- 
inal wall.  A  cathe- 
ter was  placed  in  the 
bladder  through  the 
urethra  and  allowed 
to  remain  for  several 
days.  The  abdomi- 
nal wound  was  closed 
without  drainage. 
The  patient  made  a 
good  recovery,  and 
was  about  the  house 
on    the     fourteenth 

day.  Two  months  later  Dr.  Stowell,  under  whose 
care  the  patient  had  been  originally,  told  Dr.  Weiser 
that  the  abdominal  wall  had  given  way  again  a  trifle 
lower  down  toward  the  symphysis,  and  urine  was 
again  discharging  through  a  small  sinus.  Later  the 
opening  closed  spontaneously. 

A  Very  Large  Abscess-sac  Ex- 
tending into  the  Pelvis,  Opening 
a  t  t  h  e  Umbilicus,  and  Containing 
a  Calculus.  —  This  case  in  many  respects  sug- 
gests an  umbilical  abscess  that  reaches  very  large 
proportions  and  contains  a  concretion.  On  the  other 
hand,  it  makes  one  think  of  certain  cases  of  abscess 
of  the  urachus.  I  wrote  Dr.  Weiser*  as  to  the  char- 
acter of  the  calculus.  From  his  reply  it  was  evidently 
of  urinary  origin,  and  probably  made  up  largely  of 
oxalates. 
A  woman,  seventy-five  years  of  age,  had  for  fifteen  years  suffered  inconvenience 

from  a  discharge  of  pus  from  the  umbilicus.    The  discharge  was  constant  and  at 
*  Weiser,  W.  R.:  Annals  of  Surg.,  1906,  xliv,  531. 


Fig.  253. — Urachal  Cyst.  (After  W. 
R.  Weiser,  Case  3,  Fig.  3.) 
Male,  aged  seventy-three.  The  ab- 
dominal wall  opened  spontaneously  two 
inches  below  the  umbilicus  and  urine  was 
discharged.  The  sac  extended  upward 
to  within  an  inch  of  the  umbilicus ;  down- 
ward into  the  pelvis.  It  was  intimately 
attached  to  the  fundus  of  the  bladder. 


Fig.   254. 


(After 


-Urachal   Cyst. 
W.  R.  Weiser.) 

Revised  from  Case  1.  At  the  op- 
eration Weiser  tapped  the  cyst,  evacu- 
ating five  ounces  of  horribly  fetid  pus, 
followed  by  a  calculus  weighing  70 
grains.  The  cyst  had  a  thick  and  in- 
durated wall  and  dipped  well  down 
into  the  pelvis.  It  was  extraperito- 
neal. [Dr.  Weiser  tells  me  that  in  his 
article  two  of  his  pictures  were  not 
properly  placed,  hence  the  "revi- 
sion."— T.  S.  C.l 


604  THE    UMBILICUS    AXD    ITS    DISEASES. 

times  profuse.  At  various  times  she  had  consulted  a  physician  in  reference  to  the 
condition,  but,  aside  from  prescribing  various  washes  and  ointments,  no  treatment  or 
diagnosis  was  offered. 

She  finally  consulted  Dr.  Weiser.  The  patient  at  this  time  was  well  nourished 
and  active  for  her  age.  The  abdomen  was  very  fat,  and  a  tumor  the  size  of  a  cocoa- 
nut  presented  in  the  median  line,  between  the  umbilicus  and  the  symphysis.  The 
mass  could  be  raised  with  the  abdominal  wall  and  was  apparently  attached  thereto. 

There  was  a  copious  discharge  of  foul-smelling  pus  from  the  umbilicus,  and  an 
eight-inch  probe,  passed  into  the  sinus,  failed  to  reach  the  lower  wall  of  the  sac.  The 
temperature  was  101°  F.,  her  pulse,  100.  She  volunteered  the  information  that  the 
condition  was  no  worse  than  usual,  but  that  she  was  not  feeling  well  generally,  and 
during  the  past  month  there  had  been  very  frequent  micturition. 

Under  ether  Weiser  excised  the  umbilicus  and  unhealthy  skin  surrounding  it,  and 
cutting  down  through  two  inches  of  fat,  came  upon  a  bulging  mass  extending  from 
the  umbilicus  as  far  down  as  he  could  feel  toward  the  symphysis  (Fig.  254).  This 
he  tapped,  and  evacuated  about  five  ounces  of  horribly  fetid  pus,  followed  by  a 
calculus  weighing  70  grains.  Exploration  with  the  finger  demonstrated  the  fact  that 
the  cyst  had  a  thick  and  indurated  wall,  and  dipped  well  down  into  the  pelvis.  Up  to 
this  point  in  the  operation  he  had  not  opened  the  peritoneal  cavity.  He  now  washed 
out  the  sac.  packed  it  with  gauze,  and  entered  the  peritoneal  cavity,  above  the 
location  of  the  tumor.  To  his  surprise  he  found  the  mass  densely  adherent  to  the 
intestine  posteriorly,  and  on  passing  his  hand  down  into  the  pelvis  on  the  outside  of 
the  cyst,  discovered  it  to  be  closely  associated  with  the  bladder.  He  now  concluded 
that  he  was  dealing  with  a  urachal  cyst,  and,  as  the  posterior  wall  was  almost  en- 
tirely made  up  of  intestines,  he  concluded  to  cut  away  such  portions  of  the  sac  as 
seemed  safe.  He  left  the  posterior  wall  intact,  as  well  as  that  portion  which  dipped 
down  into  the  pelvis.  The  wound  was  closed  as-  far  as  the  peritoneum,  and  the  rest 
was  walled  off  with  a  coffer-dam  drain  of  iodoform  gauze.  Her  recovery  was  un- 
eventful, but  it  required  three  months  for  the  sinus  to  close. 

March  11,  1912. 
My  Dear  Dr.  Cullen:  Replying  to  your  letter  of  the  eighth  inst.  and  referring  to 
the  urachal  calculus:   The  stone  was  quite  hard,  and  the  surface  was  dark  brown, 
resembling  in  color  a  type  of  gall-stone.     Upon  cutting  open,  the  substance  of  the 
stone  resembled  a  hard  bladder  stone  in  color  and  general  appearance. 

Unfortunately,  this  stone  was  lost  before  reaching  the  laboratory,  but  I  think  it 
was  probably  made  up  largely  of  oxalates.  My  opinion  was  that  this  was  a  urinary 
calculus  which  became  discolored  on  its  outer  strata  by  lying  in  a  bed  of  foul  pus  and 
being  exposed  through  the  discharging  sinus  at  the  umbilicus. 

Cordially  yours, 

Walter  R.  Weiser. 

Case  of  Vesico-umbilical  Fistula  of  FourteenYears' 
Standing.  —  Wbrster*  reports  the  case  of  Miss  H.,  aged  twenty-one.  She  had 
good  health  until  a  severe  attack  of  diphtheria  when  eight  years  old.  Following  this 
she  had  incontinence  of  urine  and  cystitis.  From  about  this  time  she  could  not 
straighten  herself  up  properly  and  had  a  habit  of  standing  with  the  body  bent  for- 
ward at  an  angle  of  45  degrees.     She  was  also  incapable  of  stooping  to  pick  up  any- 

*  Worster,  Joseph:   Med.  Record,  1877,  xii,  196. 


URACHAL    CAVITIES    AND    INFECTIONS.  605 

thing.  Two  years  after  the  diphtheria  she  suffered  from  a  cystitis,  accompanied  by 
a  copious  flow  of  purulent  matter  from  the  urethra,  and  shortly  afterward  a  swelling 
was  noted  in  the  umbilical  region,  the  appearance  of  which  was  followed  by  large  and 
repeated  discharges  of  pus  from  the  umbilical  opening,  and  subsequently  of  urine- 
The  umbilical  inflammation  subsided,  but  pus  escaped  from  time  to  time,  and  the 
urine  continually.  In  her  eleventh  year,  as  a  result  of  a  contusion,  an  opening 
occurred  below  the  umbilicus,  from  which  urine  escaped.  Extending  from  the  blad- 
der to  the  umbilicus  was  a  hard,  cord-like  mass,  two  inches  in  diameter  and  uniform 
in  size. 

Operation  (April  14,  1875). — Two  elliptic  incisions  were  made  and  the  umbilical 
area  removed.  Eight  days  after  the  operation  urine  escaped  from  the  wound.  A 
second  operation  was  undertaken  at  once,  with  good  results. 


LITERATURE  CONSULTED  ON  URACHAL  CAVITIES  COMMUNICATING  WITH  THE 
BLADDER  OR  UMBILICUS  OR  WITH  BOTH. 

Ball,  C.  B. :    A  Case  of  Pervious  Urachus  with  Remarkable  Disease  of  Bladder.     Trans.  Acad. 

Med.  Ireland,  1883-84,  Dublin,  1884,  ii,  376. 
Bourgeois:  Jour.  gen.  de  med.,  1821,  lxxvi,  219. 
Bramann,  F. :    Zwei  Falle  von  offenem  Urachus  bei  Erwachsenen.     Arch.  f.  klin.  Chir.,  1887, 

xxxvi,  996. 
Freer,  J.  A. :  Abnormalities  of  the  Urachus.     Annals  of  Surg.,  1887,  v,  107. 
Garrigues,  H.  J.:   Persistent  Urachus  in  an  Adult  Woman.     Med.  Record,  New  York,  1899,  lvi, 

720. 
Graf,  F. :  Urachusfisteln  und  ihre  Behandlung.     Inaug.  Diss.,  Berlin,  1896. 
Hastings,  C:    A  Singular  Case  of  Ischuria.     London  Med.  and  Phys.  Jour.,  1829,  N.  S.,  vi, 

515. 
Hind,  W. :  Diseases  of  the  Urachus  and  Umbilicus.     Brit.  Med.  Jour.,  1902,  ii,  242. 
Ill,  E.  J.:   Tumors  of  the  Urachus.     Trans.  Amer.  Assoc.  Obst.  and  Gyn.,  1892,  v,  238.     Amer. 

Jour.  Obst.,  1897,  xxxvi,  568. 
Lexer,  E.:  Ueber  die  Behandlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  1898,  lvii,  73. 
Marshall,  G.  B. :   Case  of  Patent  Urachus  over  One  Inch  in  diameter,  forming  a  Tubular  Pro- 
longation of  the  Bladder.     Jour.  Obst.  and  Gyn.  of  the  Brit.  Empire,  1907,  xi,  259. 
Matthias,  F. :   Vereiterung  des  persistierenden  Urachus  mit  Durchbruch  in  die  Blase  und  in  die 

Bauchdecken.     Beitriige  z.  klin.  Chir.;  herausg.  von  Paul  Bruns,  Tubingen,  1904,  xlii,  339. 
Monod,  J. :  Des  fistules  urinaires  ombilicales  dues  a  la  persistance  de  l'ouraque.     These  de  Paris, 

1899,  No.  62. 
Morgan,  G. :    A  Case  of  Dilated  Urachus  Accidentally  Opened  Whilst  Performing  Abdominal 

Section  for  Peritonitis;  Recovery.     The  Lancet,  1896,  ii,  1154. 
Newman,  D.:   Three  Renal  Cases,  a  Case  of  Cyst  of  the  Urachus,  and  a  Case  of  Strangulated 

Hernia,  Treated  in  the  Surgical  Wards  of  the  Glasgow  Royal  Infirmary.     Glasgow  Med. 

Jour.,  1896,  xlvi,  20. 
Nicaise:  Ombilic.     Diet,  encycloped.  des  sci.  med.,  Paris,  1881,  2.  ser.,  xv,  140. 
Patel,  M.:  Malformation  congenitale  de  l'ouraque;  dilatation  kystique  de  la  partie  interieure  de 

l'ouraque  demeure  en  communication  avec  la  vessie;    incontinence  d'urine  symptomatique. 

Capitonnage  de  la  poche.     Rev.  mensuelle  des  mal.  de  l'enfance,  Paris,  1904,  xxii,  77. 
Reid,  W.  L.:    On  the  Diagnosis  and  Treatment  of  a  Case  of  Patent  Urachus.     Glasgow  Hosp. 

Rep.,  1899,  ii,  76. 
Renard,  Gabriel:  Sur  un  kyste  de  l'ouraque.     These  de  Lyon,  1905,  No.  89. 
Robinson,  F.  B.:   Cysts  of  the  Urachus  (Congenital  Cysts,  Extraperitoneal  Cysts,  or  Dilatation 

of  Functionless  Ducts).     Annals  of  Surg.,  1891,  xiv,  336. 
Roser,  W.:    Ueber  Operation  der  Urachuscysten.     Langenbeck's  Arch.  f.  klin.  Chir.,  1877,  xx, 

473. 
Savory,  W.  S.:   Polypus  of  the  Urinary  Bladder.     Med.  Times,  London,  1852,  N.  S.,  v,  106. 


606  THE    UMBILICUS   AND    ITS    DISEASES. 

Schnellenbach:  TJeber  die  Urachuscysten.     Inaug.  Diss.,  Bonn,  1888. 

Simon,  C:  Quels  sont  les  phenoinenes  et  le  traitement  des  fistules  urinaires  ombilicales?  These 
de  Paris,  1843,  No.  80. 

Timnierman,  C.  F. :  Dilated  Urachus.     Trans.  Med.  Soc.  State  of  New  York,  1904,  331. 

Unterberger:  Retro versio-flexio  uteri  gravidi  partialis  incarcerata.  Urachus-fistel.  Monatsschr. 
f.  Geb.  u.  Gyn.,  1900,  xi,  657. 

Vaughan,  G.  T.:  Patent  Urachus.  Review  of  the  Cases  Reported.  Operation  on  a  Case  Com- 
plicated with  Stones  in  the  Kidneys.  A  Note  on  Tumors  and  Cysts  of  the  Urachus.  Trans. 
Arner.  Surg.  Assoc,  1905,  xxiii,  273. 

Weiser,  W.  R. :  Cysts  of  the  Urachus.     Annals  of  Surg.,  1906,  xliv,  529. 

Worster,  J.:  Case  of  Vesico-abdominal  Fistula  of  Fourteen  Years'  Standing.  Med.  Record, 
1877,  xii,  196. 


CHAPTER  XXXV. 
ACQUIRED  URINARY  FISTULA  AT  THE  UMBILICUS. 

General  consideration. 

Acquired  umbilical  urinary  fistula,  when  no  urethral  obstruction  exists. 

Umbilical  urinary  fistula  following  partial  or  complete  blockage  of  the  urethra. 

Urinary  fistula  at  the  umbilicus,  with  absence  of  the  urethra. 

Congenital  phimosis,  with  a  urinary  umbilical  fistula. 

Umbilical  urinary  fistula  following  stricture  of  the  urethra. 

Umbilical  urinary  fistula  associated  with  a  growth  in  the  bladder. 

Vesical  calculi  obstructing  the  urethra  and  associated  with  escape  of  urine  from  the  umbilicus; 

report  of  cases. 
Umbilical  urinary  fistula  associated  with  an  enlarged  prostate;  report  of  cases. 
Apparent  escape  of  urine  from  the  umbilicus,  the  breasts,  and  other  parts  of  the  body. 

We  have  already  considered  (p.  487)  congenital  umbilical  urinary  fistulse  due 
to  a  patent  urachus,  and  also  fistulse  resulting  from  the  opening  of  a  urachal  sac 
(p.  578).  We  shall  now  discuss  acquired  umbilical  urinary  fistulse,  occurring  appar- 
ently independently  of  urachal  cyst  formation. 

These  cases  naturally  fall  into  two  classes : 

1.  Umbilical  urinary  fistulse  when  no  urethral  obstruction  exists. 

2.  Umbilical  urinary  fistulse  associated  with  partial  or  complete  blockage  of  the 
urethra. 

Monod,  in  his  splendid  thesis  on  Umbilical  Urinary  Fistulse  Due  to  Persistence 
of  the  Urachus,  mentions  a  case  recorded  by  Laurentius  in  1600.  A  young  woman 
had  retention  of  urine  for  several  days;  this  was  followed  by  an  escape  of  urine  from 
the  umbilicus.  He  also  refers  to  an  observation  published  by  Fernel  in  1638.  A 
man,  thirty  years  old,  developed  an  umbilical  urinary  fistula  following  an  obstruc- 
tion at  the  neck  of  the  bladder.  In  the  same  thesis  reference  is  made  to  a  case 
recorded  by  Peyer  in  1721,  in  which,  following  retention  of  urine,  a  calculus  escaped 
from  the  umbilicus.  Scattered  throughout  the  literature  are  isolated  cases  of 
acquired  urinary  umbilical  fistulse. 

We  have  seen  (p.  515)  that  remnants  of  the  urachus  are  by  no  means  rare.  The 
urachus  may  remain  as  a  small,  patent  filament  connected  with  the  bladder.  In 
other  cases  the  urachus  at  the  bladder  has  been  obliterated,  but  here  and  there  along 
its  course  are  small,  spindle-like  dilatations.  In  after-life  these  small  bays  or  lakes 
may  become  connected  up  so  that  finally  there  is  produced  a  fistulous  tract  between 
the  bladder  and  umbilicus.  Where  there  is  obstruction  of  the  urethra,  it  is  only 
natural  that  the  old  channel  through  the  urachus  should  open,  but  in  those  cases  in 
which  the  urethra  is  of  normal  caliber,  the  reason  for  the  reestablishment  of  the  ura- 
chal channel  is  more  difficult  to  explain,  unless  the  urachus  has  always  been  patent 
or  unless  there  has  been  an  inflammatory  reaction  in  the  urachal  region. 

607 


608  THE    UMBILICUS    AND    ITS    DISEASES. 


ACQUIRED  UMBILICAL   URINARY  FISTULA   WHEN  NO   URETHRAL   OBSTRUCTION 

EXISTS. 

In  none  of  the  cases  here  recorded  was  any  abnormality  noted  at  the  umbilicus 
at  birth.  Five  of  the  patients  were  males  and  one  was  a  female.  The  youngest  was  a 
small  boy;  the  oldest,  eighty.  In  all  the  cases  the  urine  escaped  from  both  the 
umbilicus  and  the  urethra.  The  recognition  of  the  condition  was  eas3r  on  account  of 
the  escape  of  urine  from  the  umbilicus.  In  Binnie's  case  there  was  a  line  of  indura- 
tion between  the  symphysis  and  umbilicus.  In  Leveque-Lasource's  case  the  eighty- 
year-old  patient  had  been  passing  his  urine  at  intervals  from  the  umbilicus  for 
twenty-five  years.  In  this  case  the  possibility  of  an  enlarged  prostate  cannot  be  ex- 
cluded. 

Florentin  thought  his  patient  had  a  urinary  fistula  at  the  umbilicus.  The  his- 
tory, however,  is  not  very  conclusive. 

A  Partially  Patent  Urachus  That  Finally  Opened  at 
the  Umbilicus,  Causing  a  Urinary  Fistula.  —  Binnie,*  in 
1905,  saw  a  woman  twenty-nine  years  of  age  who  for  six  years  was  supposed  to  have 
had  cystitis  of  unknown  origin.  All  her  life  she  had  complained  of  pain  and  tender- 
ness in  the  hypogastrium,  and  Binnie  found  a  line  of  induration  between  the  bladder 
and  umbilicus.  Pus  was  escaping  from  the  umbilicus.  A  little  mass  of  granulation 
tissue  was  present  at  the  umbilicus,  and  through  this  Binnie  could  pass  a  probe  into 
the  bladder.  He  excised  the  fistula,  which  was  so  closely  attached  to  the  peritoneum 
that  the  abdomen  had  to  be  opened.  The  fistula  led  into  a  small  diverticulum  at  the 
fundus  of  the  bladder. 

On  histologic  examination  the  walls  were  found  to  consist  of  very  vascular  granu- 
lation tissue,  together  with  sclerosed  tissue.  The  lumen  was  lined  with  necrotic 
material.     No  epithelium  was  observed. 

A  Urinary  Umbilical  Fistula.!  — ■  The  man  was  thirty  years  old. 
The  urine  escaped  in  jets  from  the  umbilicus,  but  some  of  it  was  passed  through  the 
urethra. 

Possibly  a  Urinary  Fistula  at  the  Umbilicus.  —  Floren- 
tine reports  a  case  narrated  to  him  by  Professor  Froelich.  A  small  boy,  two  years  of 
age,  was  examined  at  the  hospital  of  Nancy  in  January,  1906.  At  the  umbilicus  was 
a  tumor  the  size  of  a  gooseberry  or  currant.  It  had  not  increased  in  size.  In  the 
beginning  there  had  been  no  discharge,  but  after  several  months  a  purulent  fluid 
had  commenced  to  escape  in  moderate  amount  from  a  small  ulceration  situated  at 
the  margin  of  the  elevation,  and  still  persisted.  On  examination  there  was  seen  at 
the  base  of  the  umbilical  cicatrix  a  small,  reddish  tumor  attached  to  the  skin  by  a 
broad,  short  pedicle,  from  the  base  of  which  a  little  drop  of  pus  was  being  discharged. 
The  tumor  was  irreducible.  There  was  a  small  ulceration  with  violet  margins.  In 
the  center  was  a  small  depression,  into  which  a  probe  could  be  introduced  for  3  cm. 

Operation. — The  tumor  was  continuous  with  a  fibrous  cord,  which  extended 
down  the  median  line.  It  was  dissected  out  and  tied  off,  the  outer  portion  being 
removed.     Healing  took  place.     No  microscopic  examination  was  made.     Floren- 

*  Binnie,  J.  F.:  Development  of  the  Urachus.     Jour.  Amer.  Med.  Assoc.,  1908,  ii,  109. 
t  Civiale,  Jean:  Traite  de  1' affect  ion  calculeuse,  Paris,  1838,  261. 

t  Florentin,  P. :   Fongus  de  l'ombilic  chez  le  nouveau-ne  et  chez  l'enfant.     These  de  Nancy, 
1908-09,  No.  22  (obs.  8),  108. 


ACQUIRED    URINARY    FISTULA    AT    THE    UMBILICUS.  609 

tin  diagnosed  the  condition  as  a  urinary  fistula,  but  the  case  would  seem  to  be  doubt- 
ful. 

Escape  of  Urine  From  the  Umbilicus  in  an  Old  Man,  * — 
The  patient  was  a  farmer,  eighty  years  of  age,  of  stout  build.  He  had  a  double 
inguinal  hernia.  He  had  also  had  for  a  long  period  an  umbilical  hernia,  which  was 
not  larger  than  a  chestnut.  For  twenty-five  years  at  times  the  urine  had  passed 
from  the  umbilicus,  and  sometimes  from  the  urethra.  It  did  not  escape  as  a  jet,  as 
the  opening  was  too  small,  but  there  was  enough  urine  to  keep  the  clothes  wet.  Xo 
method  of  control  had  thus  far  been  discovered.  Leveque-Lasource  said  that  the 
condition  was  due  to  the  reopening  of  the  urachus. 

A  Case  of  Fistula  of  the  Urachus.  f  —  The  patient  was  a  soldier 
in  active  service,  and  had  always  been  free  from  discomfort  except  that  the  pressure 
of  the  belt  of  his  sword  on  the  full  bladder  caused  urine  to  escape  from  the  umbilicus. 
At  the  umbilicus  the  opening  was  no  larger  than  a  hair  in  caliber,  and  even  with  a 
full  bladder  only  a  small  amount  of  urine  escaped.  He  was  given  a  small  quantity 
of  potassium  iodid  and  the  urine  soon  contained  an  appreciable  amount  of  iodin. 
The  reaction  was  obtained  from  the  umbilical  urine  by  adding  calomel,  which  at 
once  gave  it  an  intense  yellow  color. 

A  Vesico-umbilical  Fistula. ±  — -A  boy,  aged  nine,  had  had 
incontinence  of  urine,  and  from  time  to  time  had  complained  of  pain  in  the  lower 
abdomen.  For  about  six  weeks  urination  had  been  frequent,  and,  three  weeks  before 
Trogneux  saw  him,  moisture  had  been  noted  at  the  umbilicus,  and  later  a  few  drops 
of  urine  had  passed  from  the  navel.  The  urine  escaped  both  by  the  urethra  and  the 
umbilicus.  Sometimes  a  large  quantity  came  away  from  the  navel,  especially  when 
the  patient  moved.  The  umbilical  orifice  was  oval,  elongated  transversely,  and  the 
urine  escaped  from  the  bottom.  The  urethra  was  permeable.  The  bladder  held 
20  c.c.  of  fluid,  and  when  more  was  introduced,  it  at  once  escaped  by  the  umbilicus. 
The  same  result  was  obtained  in  the  reverse  direction.     The  urine  contained  pus. 

Operation. — The  tract  was  dissected  out  for  2  cm.  and  tied  off.  The  upper  part 
of  the  wound  was  closed.  The  canal  was  lined  with  what  seemed  to  be  macerated 
skin.  On  the  tenth  day  the  urine  infiltrated  the  abdominal  wall  and  escaped.  The 
boy  had  tuberculosis  in  the  apices  of  both  lungs  and  was  supposed  to  have  tuber- 
culosis of  the  bladder. 

In  this  case  the  urachus  did  not  open  until  the  ninth  year.  The  presence  of  the 
cystitis  naturally  hindered  efforts  at  rectifying  the  condition. 


UMBILICAL  URINARY  FISTULA  FOLLOWING  PARTIAL  OR  COMPLETE  BLOCKAGE  OF 

THE  URETHRA. 

Although  in  the  majority  of  the  cases  the  definite  type  of  obstruction  to  the 
escape  of  urine  from  the  urethra  has  been  stated,  in  a  few  cases  it  is  merely  recorded 
that  an  obstruction  existed. 

Monod  refers  to  an  observation  made  b}T  Fernel  in  1638.     A  man,  aged  thirty, 

*  Leveque-Lasource:  D'un  cas  particulier  ou  les  urines  sortaient  par  l'ombilic.  Jour,  de 
med.,  Paris,  1811,  xxi,  121. 

t  Starcke:   Deutsche  militararztliche  Zeitschr.,  1883,  xii,  211. 

%  Trogneux,  Albert:    Contribution  a  l'etude  des  fistules  ombilico-vesicales.     These  de  Paris, 
1897,  No.  129. 
40 


610  THE    UMBILICUS    AND    ITS    DISEASES. 

developed  an  umbilical  urinary  fistula  following  an  obstruction  at  the  neck  of  the 
bladder. 

Littre*  reported  the  case  of  a  boy  twelve  years  of  age  who  had  passed  nearly  all 
his  urine  by  the  umbilicus.  At  autopsy  an  obstruction  was  found  at  the  neck  of  the 
bladder  and  the  urachus  had  remained  as  a  patent  canal.  Littre,  in  the  same  article, 
says  that  he  knew  a  man  thirty  years  old  from  whom  the  urine  escaped  forcibly  from 
the  umbilicus,  no  doubt  as  the  result  of  an  obstruction  at  the  neck  of  the  bladder. 

Simon  (obs.  14)  records  a  case  reported  by  Chopart.f  I  have  attempted  to  find 
the  original  article,  but  was  unable  to  locate  it.  It  is,  however,  probably  correct,  as 
Chopart  has  many  cases  scattered  throughout  his  excellent  book. 

The  patient  was  a  woman,  thirty-seven  years  of  age.  Shortly  after  the  beginning 
of  pregnancy  she  suffered  from  retention  of  urine,  and  twelve  days  later  several  drops 
of  puriform  urine  escaped.  The  abdomen  increased  in  size  day  by  day,  and  when 
she  entered  the  hospital  on  September  7, 1781,  she  complained  of  abdominal  tender- 
ness. The  skin  was  inflamed,  and  there  was  marked  fluctuation  around  the  umbili- 
cus; the  patient  voided  only  in  small  quantities.  She  had  high  fever.  Anthelme, 
surgeon-in-chief  of  the  hospital,  made  an  incision  in  the  linea  alba  between  the 
umbilicus  and  the  muscle  on  the  right,  and  a  good  deal  of  pus  and  a  large  quantity  of 
fetid  urine  escaped.  On  the  following  day  the  symptoms  were  less  acute.  The 
clothes  and  the  body  were  inundated  with  urine,  and  a  large  quantity  of  pus  also 
escaped.  On  the  next  day  the  clothes  were  soaked  with  urine.  The  fever  and  other 
symptoms  had  disappeared,  and  the  surgeon  attempted  to  establish  the  return  of  the 
urine  by  the  urethra.  He  was  unable  to  introduce  a  sound  into  the  bladder  on 
account  of  some  obstruction.  Later  on  he  was  able  to  pass  an  elastic  catheter  into 
the  bladder.  The  amount  of  urine  escaping  from  the  umbilicus  diminished,  and  the 
pus  in  the  urine  gradually  decreased.  The  pregnancy  continued,  and  the  patient 
left  the  hospital  perfectly  well.     Normal  labor  took  place  in  February,  1782. 

Simon  J  says  that  at  the  meeting  of  the  Medical  Society  in  Florence,  July  13, 
1828,  Betti  reported  a  case  seen  by  Falaschi,  in  which,  as  a  result  of  a  complete 
occlusion  of  the  urethra  at  its  vesical  orifice,  there  was  an  escape  of  urine  from  the 
umbilicus  in  a  patient  very  advanced  in  years.  This  phenomenon  was  observed  for 
several  months  before  death. 

The  various  causes  of  blockage  of  the  urethra  have  been: 

1.  A  congeni tally  closed  urethra. 

2.  A  congenital  phimosis. 

3.  A  stricture  following  gonorrhea. 

4.  New-growths  of  the  bladder. 

5.  A  vesical  calculus. 

6.  An  enlarged  prostate. 


URINARY  FISTULA  AT  THE  UMBILICUS,  WITH  ABSENCE  OF  THE  URETHRA. 
The  only  case  of  congenital  absence  of  the  urethra  with  the  escape  of  urine  from 
the  umbilicus  with  which  I  am  familiar  is  that  reported  by  Petit  in  1837. 

*  Littre:   Histoire  de  l'Academie  Royale  des  Sciences  de  Paris,  Amsterdam,  1701,  27. 
t  Chopart:    Maladies  des  voies  urinaires,  Paris,  1792. 
X  Simon:  Obs.  17,  p.  33. 


ACQUIRED    URINARY    FISTULA   AT    THE    UMBILICUS.  611 

Urinary  Fistula  at  the  Umbilicus,  With  Absence  of 
the  Urethra.*  —  The  child  was  born  with  a  closed  urethra.  At  the  umbilical 
cicatrix  was  a  tumor  the  size  of  a  cherry,  from  which  urine  escaped.  A  bandage  was 
applied.  The  bandage  retained  the  urine  very  well,  but  she  was  often  obliged  to 
remove  it  in  order  to  relieve  herself.  The  bladder  was  sensitive  and  did  not  hold 
more  than  half  a  glass  of  urine.  As  soon  as  it  reached  this  degree  of  dilatation  the 
child  suffered  from  pain  in  the  abdomen,  particularly  in  the  region  of  the  bladder 
and  the  kidneys. 


CONGENITAL  PHIMOSIS  WITH  A  URINARY  UMBILICAL  FISTULA. 
Freer,  in  his  article  on  Abnormalities  of  the  Urachus,  refers  to  an  article  appear- 
ing in  the  Medical  Record  of  August  18,  1871.  A  boy,  a  year  old,  commenced  to 
pass  his  urine  through  a  vesico-umbilical  fistula.  A  few  drops  only  passed  by  the 
urethra.  An  examination  revealed  a  congenital  phimosis  with  an  orifice  so  small 
that  the  vis  a  tergo  required  to  force  the  urine  through  it  had  exerted  itself  in  an 
upward  direction  and  had  opened  up  the  urachus,  rendering  that  structure  patent 
throughout.  After  this  fistula  had  persisted  for  some  time  the  cause  was  discovered, 
•  circumcision  was  performed,  and  the  urachus  closed  spontaneously. 

Freer  says  this  case  emphasizes  the  importance  of  examining  carefully  the  urethra 
before  proceeding  to  operate  for  the  closure  of  the  fistula. 


UMBILICAL  URINARY  FISTULA  FOLLOWING  STRICTURE  OF  THE  URETHRA. 

This  is  a  very  rare  condition,  considering  the  enormous  number  of  patients  who 
suffer  from  urethral  stricture.  Jacoby  reported  a  case  in  1877,  and  Guisy  two  cases 
in  1903.  One  of  Guisy's  patients  also  had  an  enlarged  prostate  which  was  probably 
a  contributory  factor  to  the  urethral  obstruction. 

Umbilical  Fistula  Following  a  Urethral  Stricture. f 
—  The  patient  was  a  boy,  eighteen  years  of  age,  who  had  contracted  gonorrhea  a 
year  before  and  had  developed  a  stricture.  Later  there  was  a  perineal  fistula. 
After  taking  balsam  of  copaiba  he  improved  somewhat,  but  three  months  later  the 
urine  stopped  completely  for  twenty-four  hours.  He  suffered  great  pain  and  the 
umbilicus  opened.  Pus  escaped,  and  then  large  quantities  of  urine,  the  continuous 
flow  confining  him  to  bed.  When  Jacoby  saw  him  he  had  tuberculosis  and  syphilis. 
All  the  urine  came  from  the  umbilical  fistula  and  none  from  the  urethra.  The  fistula 
in  the  perineum  was  dry. 

The  umbilicus  was  flat.  There  was  a  very  narrow  fistula.  Once  the  fistula 
closed  and  a  small  amount  of  urine  escaped  from  the  urethra.  At  the  end  of  thirty 
hours,  when  the  patient  bore  down  heavily,  the  fistula  reopened,  and  fully  a  quart  of 
urine  came  away.  This  was  mixed  with  pus  and  blood.  The  boy  soon  died.  No 
autopsy  is  recorded. 

An  Umbilical  Urinary  Fistula  Developing  in  a  Man 
with  Urethral  Stricture  and  Enlarged  Prostate.  — •  Guisy'sJ 

*  Petit,  J.  L.:  Traite  des  mal.  chirurg.,  Chap,  xi,  3.  Oeuvres  completes,  8°.  Limoges, 
1837.     (Quoted  by  Simon,  obs.  8.) 

t  Jacoby,  M.:   Zur  Casuistik  der  Nabelfisteln.     Berlin,  klin.  Wochenschr.,  1877,  202. 

J  Guisy,  B.:  Deux  cas  de  permeabilite  congenitale  de  l'ouraque.  Ann.  d.  mal.  d.  org. 
genito-urin.,  Paris,  1903,  xxi,  986. 


612  THE    UMBILICUS    AND    ITS    DISEASES. 

patient  was  a  man  sixty  years  of  age,  who,  for  five  years,  had  been  passing  urine  from 
the  umbilicus.  His  previous  history  showed  that  he  had  suffered  many  years  before 
with  gonorrhea,  and  later  with  severe  attacks  of  renal  colic,  accompanied  by  the 
passage  of  gravel  from  the  urethra.  He  also  had  a  urethral  stricture.  He  developed 
pain  and  swelling  about  the  navel.  A  physician  opened  the  swelling  and  evacuated 
urine  and  pus,  and  thereafter  the  urine  continued  to  flow  by  this  route,  as  well  as 
through  the  urethra.  External  urethrotomy  was  performed,  and  two  large  stones 
were  removed  from  behind  the  stricture.  The  prostate  was  large.  The  urine  ceased 
completely  to  flow  from  the  umbilicus  and  recovery  took  place. 

Escape  of  Urine  from  the  Umbilicus  Following  Stric- 
ture of  the  Urethra.  —  Guisy's*  second  patient  was  a  man  aged  thirty- 
two  years,  who,  on  account  of  stricture  following  gonorrhea,  had  had  great  difficulty 
in  passing  urine  and  for  two  years  had  suffered  pain  at  the  umbilicus.  Later  a 
swelling  appeared,  and  one  day,  during  complete  retention,  the  tumor  ruptured 
and  urine  and  bloody  mucus  escaped.  Thereafter  for  several  months  there  was  con- 
stant leakage  from  the  navel.  A  small  sound  could  be  passed  through  the  navel 
into  the  bladder.  The  urethral  stricture  was  treated  by  internal  urethrotomy  and 
dilatation,  and  the  escape  of  urine  through  the  navel  diminished  materially. 


UMBILICAL  URINARY  FISTULA  ASSOCIATED  WITH  A  GROWTH  IN  THE  BLADDER. 

The  only  case  of  this  character  with  which  I  am  familiar  is  the  one  reported  by 
Cadell  in  1878. 

Marked  Cystitis  in  a  Young  Girl  Followed  by  Escape 
of  Urine  from  the  Umbilicus. f  —  The  patient  was  a  delicate  girl 
eight  years  of  age.  From  her  earliest  childhood  she  had  difficulty  in  making  water. 
Micturition  was  frequent,  and  only  a  small  amount  of  urine  was  passed.  When  she 
was  six  months  old  the  lower  abdomen  and  genitals  became  black  and  blue.  The 
child  went  to  school  at  four,  but  was  taken  home  on  account  of  pain  and  frequent 
urination.  After  an  attack  of  typhoid  fever  at  six  years  of  age  the  other  symptoms 
became  more  marked.  Eight  months  before  admission  blood  was  noted  in  the 
urine.  After  a  few  days  of  great  pain  and  swelling  and  hardness  of  the  abdomen,  the 
urine  was  observed  to  come  in  a  small  stream  from  the  umbilicus.  Nothing  ab- 
normal was  noted  in  the  appearance  of  the  umbilicus  or  of  the  genitals.  In  the 
center  of  the  umbilical  depression  was  a  fistulous  opening  into  which  a  probe  could 
be  easily  introduced  and  passed  toward  the  bladder.  A  No.  2  elastic  catheter  intro- 
duced through  the  urethra  was  blocked  by  tenacious,  mucopurulent  masses  in  the 
bladder.  The  urethra  was  normal.  No  urine  escaped  by  the  urethra  for  several 
days.  Later  the  urethra  was  dilated  under  anesthesia,  and  the  procedure  was  fol- 
lowed by  incontinence  of  urine. 

The  child  died  a  few  months  later.  At  autopsy  the  bladder  was  found  contracted 
and  showed  great  thickening  of  the  mucous  and  submucous  coats.  Protruding  into 
the  cavity  were  rounded  nodules  the  size  of  peas.  At  the  upper  end  of  the  bladder 
was  the  unobliterated  urachus.  It  admitted  the  point  of  the  little  finger,  gradually 
became  narrower,  and  at  the  umbilicus  admitted  a  No.  5  or  No.  6  catheter.     The 

*  Guisy,  B.:   Loc.  eit. 

t  Cadell,  F.:    Notes  on  a  Case  of  Umbilical  Urinary  Fistula.    Edinburgh  Med.  Jour.,  1878, 
xxiv,  Part  i,  221. 


ACQUIRED    URINARY    FISTULA    AT    THE    UMBILICUS.  613 

mucous  membrane  of  the  urachus  was  thin  and  pale.  Between  the  umbilicus  and 
the  bladder  were  evidences  of  an  old  peritonitis,  and  the  omentum  was  adherent  to 
the  anterior  abdominal  wall  along  the  course  of  the  urachus.  There  were  dense 
adhesions  binding  the  uterus  to  the  posterior  surface  of  the  bladder. 

The  right  kidney  was  twice  the  natural  size,  cystic,  and  filled  with  putrid  and 
ammoniacal  pus.  There  was  complete  atrophy  of  the  kidney  substance.  The  left 
kidney  was  one  and  a  half  times  the  natural  size.  The  calices  were  distended  with 
putrid  pus,  but  the  kidney  substance  had  been  only  partially  destroyed.  Both 
ureters  were  dilated.     Cadell  says  the  urachus  must  have  been  partly  open  at  birth. 


VESICAL  CALCULI  OBSTRUCTING  THE  URETHRA  AND  ASSOCIATED  WITH  ESCAPE 
OF  URINE  FROM  THE  UMBILICUS. 

Cases  of  this  nature  have  been  reported  by  Littre  (1701),  Raussin  (1752), 
d'Auxiron  (1766),  Eustache  (1789),  Civiale  (1838),  Simon  (1843),  and  Lexer  (1898). 
In  seven  cases  in  which  the  sex  was  mentioned,  five  were  in  males  and  two  in  females. 
The  ages  varied  from  two  and  a  half  to  seventy  years.  The  age  at  which  the  patient 
came  under  observation  is,  however,  no  index  as  to  when  the  symptoms  first  devel- 
oped. For  example,  d'Auxiron's  patient  came  under  observation  when  he  was 
seventy  years  old,  but  from  the  history  it  will  be  seen  that  he  had  had  vesical 
symptoms  since  childhood.  Eustache's  patient,  a  boy  six  years  old,  had  vesical 
symptoms  shortly  after  birth. 

The  symptoms  were  usually  those  referable  to  a  vesical  calculus,  and  after  vari- 
ous periods  of  time  urine  commenced  to  escape  from  the  umbilicus.  In  some  cases 
the  umbilical  fistula  was  preceded  by  an  inflammatory  reaction  in  the  umbilical 
region;  in  other  cases  this  phenomenon  was  apparently  lacking. 

Some  of  the  patients  were  relieved  by  lateral  lithotomy,  and  in  Simon's  case  the 
stone  was  successfully  removed  suprapubically.  After  removal  of  the  stone  the 
umbilical  fistula  usually  closed. 

With  our  present  mode  of  treatment  these  patients  would  naturally  be  operated 
upon  soon  after  symptoms  develop.  If  there  be  little  or  no  infection,  the  fistulous 
tract  should  be  dissected  out  and  excised,  and  the  stone  removed  suprapubically  at 
the  same  time.  When  the  inflammatory  reaction  is  marked,  the  stone  may  be 
removed  and  the  tract  dissected  out  after  the  inflammation  has  subsided. 


CASES  OF  VESICAL  CALCULUS  WITH  ESCAPE  OF  URINE  AT  THE  UMBILICUS. 
Vesical  Calculi  Followed  by  Escape  of  Urine  at  the 
Umbilicus.*  —  The  patient  was  a  priest,  seventy  years  of  age,  who  had  suf- 
fered with  vesical  stone  since  childhood.  He  had  piercing  pains  in  the  lower  ab- 
domen at  times,  and  suffered  from  retention  of  urine,  which  sometimes  lasted  for 
several  days. 

For  four  or  five  years  stones  had  blocked  the  urethra,  and  the  urine  had  at  times 
escaped  from  the  umbilicus.  There  was  a  small  opening  with  reddish  margins  at  the 
umbilicus,  out  of  which  the  urine  oozed.  Sometimes  it  came  as  a  stream  and  could 
be  caught  in  a  vessel.  When  the  urine  escaped  by  the  ordinary  channel,  the  umbili- 
cal opening  would  close. 

*  d'Auxiron:  Une  observation  sur  un  homme  qui  rend  ses  urines  par  le  nombril.  Jour,  de 
m£d.,  Paris,  1766,  xxiv,  58. 


614  THE    UMBILICUS   AND    ITS    DISEASES. 

Escape  of  Urine  from  the  Umbilicus  Due  to  a  Vesical 
Calculus.*  —  In  a  patient  seventy  years  old  the  urine  escaped  from  the  umbili- 
cus in  jets,  in  spite  of  the  fact  that  the  bladder  was  not  extremely  full.  Each  time  it 
was  found  that  a  stone  was  obstructing  the  neck  of  the  bladder. 

Escape  of  Urine  from  the  Umbilicus,  Due  to  the  Pres- 
ence of  a  Vesical  Calculus.  —  Civiale  f  says  that  Fourquet,  of  Tou- 
louse, narrated  to  him  the  history  of  a  child,  thirty-one  months  of  age,  who  was  re- 
lieved by  lithotomy.  The  vesical  stone  was  voluminous,  weighing  5.5  "gros,"  and 
enveloped  in  a  covering  of  mucus  and  calcareous  material.  After  about  two  months, 
as  a  result  of  considerable  effort,  the  child  expelled  urine.  It  developed  a  urinary 
fistula  at  the  umbilicus,  from  which  three  quarts  or  less  of  urine  escaped.  This 
closed  after  the  operation. 

Umbilical  Urinary  Fistula  Associated  With  Stone 
Situated  in  the  Neck  of  the  Bladder.  —  Civiale  also  reports  a 
case  related  by  Covillard.  The  patient,  a  girl  fifteen  years  of  age,  passed  her 
urine  from  the  umbilicus,  and  a  stone  was  detected  in  the  neck  of  the  bladder.  A 
lateral  lithotomy  effected  an  entire  cure. 

Urachal  Fistula  at  the  Umbilicus  Associated  With  a 
Stone  in  the  Bladder.  —  Lexer  J  reported  a  case  that  came  under  Gold- 
schmidt's  care.  Goldschmidt  operated  on  a  ten-year-old  boy  on  account  of  the 
gradual  appearance  of  a  fistula  without  signs  of  inflammation.  This  case  was  looked 
upon  as  one  of  urachal  fistula  of  the  abdominal  wall,  although  no  microscopic  exam- 
ination could  be  made.  The  boy  had  a  large  stone  in  the  bladder.  The  fistula 
had  produced  an  abscess-like  dilatation  below  the  umbilicus,  and  had  been  pre- 
viously opened.  At  another  time,  when  the  cystitis  had  disappeared,  the  umbilical 
opening  closed. 

[This  case  is  not  particularly  clear. — T.  S.  C] 

Blockage  of  the  Neck  of  the  Bladder  by  a  Stone;  Par- 
tially Patent  Urachus.  — ■  Littre  §  demonstrated  before  the  Paris  Acad- 
emy the  body  of  a  young  man  of  eighteen.  The  neck  of  the  bladder  was  occupied  by 
a  stone,  and  the  urachus  at  the  neck  of  the  bladder  was  open  for  five  fingerbreadths. 
He  says  that  when  the  urine  finds  great  difficulty  in  passing  along  its  ordinary  route, 
it  commences  to  travel  through  its  ancient  channel. 

A  Renal  Calculus  Associated  with  Escape  of  Urine  b  y 
the  Umbilicus.  —  Raussin||  reported  before  the  Academy  the  case  of  a  man, 
aged  thirty-two  years,  who  had  had  a  renal  calculus.  In  making  an  effort  to  urinate, 
while  an  attendant  held  the  vessel,  expecting  to  see  a  small  stone  fall  into  the  vessel, 
he  was  greatly  surprised  to  see  urine  passing  from  the  umbilicus  and  from  the  penis 
at  the  same  time.  The  umbilical  stream  was  well  formed,  and  made  an  arch  over 
the  shoulder  of  the  servant,  who  at  the  time  was  kneeling.  The  umbilicus  of  the 
patient  was  represented  as  a  tumor  the  size  of  a  medium-sized  walnut,  with  an  open- 
ing in  it  which  discharged  a  little  blood.     The  patient  continued  to  urinate  by  the 

*  Civiale,  Jean:  Traitc  de  l'affection  calculeuse,  Paris,  1838,  257. 
;  ( Jiviale,  Jean:  Op.  cit. 

%  Lexer,  E.:  Ueber  die  Behandlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  1898,  lvii,  73. 
§  Littre:    Sur  un  foetus  extraordinaire.      Histoire  de  l'Academie  Royale  des  Sciences  de 
Paris,  Amsterdam,  1701,  27. 

1 1  Raussin :  L'urine  rendue  par  le  nombril.     Mem.  de  l'Acad.  de  Chir.,  Paris,  1752,  ih,  10. 


ACQUIRED    URINARY    FISTULA    OF    THE    UMBILICUS.  615 

umbilicus  more  than  by  the  urethra,  and  claimed  to  be  able  to  urinate  by  one  or 
the  other,  as  he  desired.     After  a  time  most  of  the  urine  passed  by  the  urethra. 

Escape  of  Urine  by  the  Umbilicus  Due  to  Blockage  of 
the  Urethra  by  a  Vesical  Calculus.*  —  Dr.  Eustache,  surgeon- 
in-chief  of  the  Hotel-Dieu  of  Beziers,  reported  before  the  Academy  of  Surgery,  in 
1789,  the  case  of  a  new-born  boy  who  developed  severe  abdominal  pain  a  few  days 
after  his  birth.  He  was  thought  to  have  colic,  but  the  usual  remedies  were  given  with- 
out success.  At  the  thirteenth  month  he  was  weaned.  The  manner  in  which  he  urin- 
ated led  to  the  supposition  that  he  had  a  stone.  When  he  was  three  years  of  age  he 
drank  to  excess,  and  one  day  he  consumed  a  pint  of  wine  and  became  unconscious. 
The  difficulty  in  urination  increased.  Sometimes  he  would  have  incontinence  of 
urine,  sometimes  a  dozen  hours  would  pass  without  there  being  the  escape  of  a  drop. 
When  five  years  of  age  he  had  complete  retention  of  urine,  and  his  abdomen  was 
tender  and  painful,  especially  in  the  hypogastric  region.  His  pulse  was  small  and 
rapid,  and  the  respiration  was  embarrassed.  He  had  continual  nausea.  Pistre  saw 
him  on  the  third  day,  and  at  that  time  he  had  around  the  umbilicus  a  tumor  which 
was  inflamed,  tender,  and  painful.  Poultices  were  applied,  and  on  the  fourth  day 
the  child  had  not  passed  a  drop  of  urine  and  was  unconscious.  On  the  fifth  day 
there  formed  in  the  center  of  the  umbilical  tumor  an  opening  about  half  an  inch  in 
diameter,  and  from  this  urine  with  pus  escaped.  Little  by  little  the  symptoms 
disappeared.  The  stomach  retained  nourishment,  and  he  returned  to  the  condition 
that  he  was  in  before  the  retention.  The  umbilical  opening  remained  as  a  fistula 
and  was  the  only  passage  by  which  the  urine  escaped.  On  the  twenty-fourth  of 
April,  1787,  Eustache  saw  this  patient,  who  was  then  six  and  a  half  years  old.  He 
had  a  slight  fever  and  marasmus.  Eustache  confirmed  the  opinion  of  Pistre  of  the 
existence  of  a  stone  in  the  neck  of  the  bladder,  because  a  sound  was  arrested  at  this 
place  and  came  in  contact  with  a  hard  body.  On  the  seventh  of  May  of  the  same 
year,  in  the  presence  of  several  surgeons,  Eustache  extracted  the  stone  through  an 
incision  in  the  perineum.  It  was  in  the  shape  of  a  large  horn,  and  the  lower  extrem- 
ity was  engaged  in  the  urethra.  It  was  a  little  less  than  three  inches  long  and  13^ 
inches  in  diameter.  It  was  slightly  concave  toward  the  pubes,  convex  toward  the 
rectum.  After  the  extraction  of  the  stone  the  urine  commenced  to  escape  through 
the  wound,  and  in  a  short  time  the  fistulous  opening,  which  had  been  present  for  a 
year,  closed.  The  urine  contained  much  mucus.  On  the  thirty-second  day  after 
the  operation  the  urine  commenced  to  pass  by  the  urethra,  and  ten  days  later  it 
passed  entirely  through  this  channel.     The  child  made  a  good  recovery. 

Escape  of  Urine  From  the  Umbilicus  Due  to  Blockage 
of  the  Urethra  by  a  Vesical  Calculus.  —  Simon  f  reports  the  case 
of  Marguerite  P.,  aged  twelve  years,  who  had  urinated  by  the  umbilicus  for  four 
years.  During  this  time  not  a  drop  of  urine  had  escaped  by  the  urethra.  She  had  an 
enlargement  of  the  abdomen,  due  to  the  escape  of  urine  into  the  cellular  tissue  of  the 
skin  and  of  the  muscle.  She  was  brought  to  the  hospital  in  May,  1786.  With  a 
sound  an  obstruction  was  found  in  the  canal,  which  was  preventing  the  flow  of  urine. 
The  opening  in  the  umbilical  region  offered  a  channel  which  communicated  with  the 
bladder.  By  this  means  it  was  possible  to  detect  a  stone  fixed  in  the  inner  orifice  of 
the  urethra.  The  surgeon  decided  to  pass  a  sound  into  the  bladder  by  way  of  the 
urachus.  The  child  was  laid  upon  the  table,  the  head  and  the  buttocks  being  a  little 
*  Simon:  These  de  Paris,  1843  (obs.  19),  34.  f  Simon:  Op.  cit.  (obs.  25),  44. 


616  THE    UMBILICUS    AND    ITS    DISEASES. 

elevated.  After  the  sound  had  been  introduced  into  the  bladder  by  way  of  the 
urachus  an  incision  was  made  in  the  skin  for  about  the  length  of  three  fingerbreadths 
in  the  linea  alba,  and  ending  at  the  pubes.  The  sound  acted  as  a  guide.  The 
bladder  was  opened.  The  stone  was  the  size  of  a  pigeon's  egg.  After  the  extraction 
of  the  stone  the  child  was  promptly  put  to  bed,  and  a  sound  was  introduced  through 
the  urethra.     At  the  end  of  four  months  the  urine  escaped  regularly  by  the  urethra. 


UMBILICAL  URINARY  FISTULA  ASSOCIATED  WITH  AN  ENLARGED  PROSTATE. 

Levie,  Lexer,  and  Monod  have  recorded  cases  in  which  a  urinary  fistula  devel- 
oped at  the  umbilicus  in  patients  suffering  from  an  enlarged  prostate. 

In  this  connection  it  may  be  mentioned  that,  according  to  Kirmisson,  Horion 
observed  an  umbilical  fistula  that  had  developed  after  retention  caused  by  a 
prostatic  abscess. 

A  P  a  t  e  n  t  U  r  a  c  h  u  s  A  s  s  o  c  i  a  t  e  d  W  i  t  h  an  Enlarged  Pros- 
tate.* —  The  patient  was  a  man  seventy-nine  years  of  age.  After  several 
years  of  dysuria  due  to  an  enlarged  prostate,  the  urine  commenced  to  escape  from 
the  umbilicus.  At  autopsy  the  urachus.  was  found  open.  The  opening  into  the 
bladder  was  tubular.     The  opening  was  from  1  to  1.5  mm.  broad. 

Markedly  Enlarged  Prostate,  Followed  by  Cystitis 
and  Escape  of  Urine  From  the  Umbilicus.  —  Lexer  f  reports  the 
case  of  a  man,  aged  sixty-seven,  who  came  to  the  clinic  for  three  years  on  account  of 
a  prostatic  hypertrophy  and  a  resulting  cystitis.  He  came  whenever  retention  of 
urine  developed.  The  urine  was  removed  with  a  soft  catheter,  and  the  bladder 
washed  out  each  time.  The  patient,  on  coming  to  the  hospital  later,  said  that,  after 
there  had  been  a  stoppage  of  urine  for  twenty-four  hours,  it  had  commenced  to  come 
away  by  the  umbilicus.  He  had  noticed  no  unusual  pain,  and  there  was  no  inflam- 
mation in  the  region  of  the  umbilicus.  The  entire  flow  of  purulent,  slimy  urine  es- 
caped from  the  umbilicus. 

On  examination  the  patient  was  found  to  have  a  markedly  enlarged  prostate. 
A  sound  could  be  carried  from  the  umbilicus  for  6  cm.  toward  the  bladder.  From 
the  umbilicus  to  the  symphysis  in  the  middle  line  a  cord-like  mass  could  be  felt.  [In 
such  a  case  it  would  now  be  very  easy  to  use  bismuth  paste  and  get  a  clear  picture  of 
the  character  of  the  fistulous  tract  by  means  of  the  x-ray. — T.  S.  C] 

Lexer  said  that  the  almost  complete  lack  of  symptoms  in  the  development  of  the 
fistula  was  a  strong  indication  against  perforation  of  the  bladder  with  infiltration  of 
the  urine.  He  says  that,  in  view  of  the  slow  development  and  the  fact  that  the  posi- 
tion of  the  fistulous  tract  was  exactly  in  the  mid-line,  the  whole  picture  tends  to 
prove  that  the  case  was  one  of  urachal  fistula. 

[With  the  present  brilliant  results  obtained  by  prostatectomy,  as  carried  out  by 
Young  and  others  in  this  country,  the  first  thing  would  be  to  remove  the  prostate; 
this  would  materially  improve  matters,  and  later,  if  necessary,  the  fistulous  tract 
could  be  closed.— T.  S.  C] 

With  a  sound  in  the  tract  Lexer  divided  it.  It  was  surrounded  on  all  sides  by 
very  firm  connective  tissue,  and  about  5  cm.  above  the  symphysis  he  found  a  cavity 

*  Levie,  L. :    Een  geval  van  profluvium   urinae  per  umbilicum   ab  uracho  patente  bij   een 
volwassen  persoon.     Nederlandsch.  Tijdschrift  voor  Geneeskunde,  1878,  xiv,  501. 
t  Lexer,  E.:   Loc.  cit. 


ACQUIRED    URINARY    FISTULA    AT   THE    UMBILICUS.  617 

the  size  of  a  walnut  lined  with  slimy  granulations  and  filled  with  purulent  urine. 
This  lay  behind  the  abdominal  wall  and  reached  to  the  symphysis.  The  sac  com- 
municated with  the  bladder  by  a  fistulous  opening,  the  size  of  a  lead-pencil.  The 
entire  wound  was  packed  with  iodoform  gauze  and  a  retention  catheter  left  in. 

The  patient  died  fourteen  days  later  with  signs  of  uremia  and  fever.  At  autopsy 
a  marked  pyonephrosis  was  found  on  both  sides.  The  small,  thick-walled,  ulcer- 
ated bladder  ended  in  a  small  funnel  just  in  the  mid-line.  Here  it  communicated 
with  the  opening  in  the  abscess-sac.  On  the  inner  side  of  the  abdominal  wall  was 
the  median  vesical  ligament,  appearing  as  a  prominent  cord  2  cm.  broad. 

From  the  results  of  the  operation  and  from  the  autopsy  specimen,  it  is  clear  that 
the  bladder  and  umbilical  fistula  lay  in  the  mid-line,  and  in  the  very  markedly  thick- 
ened median  vesical  ligament.  The  opening  in  the  bladder  was  situated  exactly  in 
the  middle  of  the  vertex  and  in  front  of  the  peritoneum.  In  the  fistulous  tract  it 
was  impossible  to  make  out  any  epithelium. 

Lexer  comes  to  the  conclusion  that  these  fistulous  tracts  should  be  dealt  with 
early,  before  there  is  much  inflammation;  that  is,  in  childhood. 

Umbilical  Urinary  Fistula  Associated  With  Hyper- 
trophy of  the  Prostate.*  —  This  case  is  particularly  interesting.  In  a 
man,  sixty-two  years  of  age,  the  umbilical  fistula  developed  after  a  prostatic  hyper- 
trophy. On  looking  into  the  history  it  was  found  that  the  patient  had  urinated  from 
the  umbilicus  from  the  time  of  birth  until  he  was  three  weeks  old.  The  fistula  had 
then  closed  spontaneously  after  the  application  of  appropriate  bandages. 

Enlargement  of  the  prostate  is  relatively  common,  and  notwithstanding  the 
tension  under  which  the  bladder  labors  in  some  of  these  cases,  the  escape  of  urine 
from  the  umbilicus  is  exceptional.  It  really  seems  as  if  the  umbilical  fistula  only 
develops  in  those  cases  in  which  the  urachus  has  remained  partially  patent,  or  where 
its  lumen  has  persisted  almost  to  the  umbilicus. 

-  Bardeleben  and  Chapin  have  also  reported  cases  in  which  an  enlarged  prostate 
probably  existed.  Bardeleben's  patient  was  ninety-two,  Chapin's  was  sixty-six, 
years  old. 

A  Urinary  Fistula  at  the  Umbilicus  Developing  in  a 
Man  Ninety-two  Years  of  Age.  — ■  Bardelebenf  says  that,  in  the 
Memoires  de  l'Academie  des  Sciences  for  1769,  there  is  a  report  of  a  man,  ninety- 
two  years  old,  who  had  severe  pain  in  the  neck  of  the  bladder  for  several  days. 
After  the  pain  had  ceased,  he  noticed  that  he  voided  less  urine  than  usual  and  that 
his  umbilicus  was  wet.  A  clear  fluid  (urine)  was  found  escaping  from  the  umbilicus. 
In  fourteen  days  the  urine  by  the  urethra  ceased.  He  died  in  six  months.  The 
fistula  persisted  until  his  death. 

Escape  of  Urine  from  the  Umbilicus  in  a  Man  Sixty- 
six  Years  of  Age.  —  Chapin's  f  patient  was  a  man,  sixty-six  years  of  age,  who 
was  seen  in  June  with  retention  of  urine.  He  suffered  a  great  deal  of  pain  and 
passed  no  urine  for  forty  hours.  The  urine  then  began  to  dribble,  and  finally  the 
bladder  was  emptied  with  a  catheter.     He  suffered  agony  beyond  expression  during 

*  Jaboulay:   Reported  by  Monod,  Obs.  53. 

f  Bardeleben:   Lehrbuch  der  Chirurgie  und  Operationslehre,  1882,  iv,  223. 
t  Chapin,  Edward:    A  Case  of  Open  or  Patent  Urachus.     North  Amer.  Jour,  of  Homoeop- 
athy, New  York,  1897,  third  series,  xii,  286. 


618  THE    UMBILICUS   AND    ITS    DISEASES. 

the  retention.  The  catheter  was  used  for  several  days,  after  which  he  developed  a 
great  deal  of  soreness  over  the  upper  part  of  the  bladder.  Palpation  over  this 
region  was  painful.  His  pulse  was  slightly  accelerated,  but  he  had  no  fever.  He 
voided  small  quantities  of  strongly  ammoniacal  urine  containing  mucus.  Later  ex- 
coriations were  noted  around  the  umbilicus,  and  some  pus  escaped  from  this  opening. 
The  discharge  became  more  watery  and  had  the  odor  of  urine.  The  amount  of 
urine  escaping  gradually  increased,  and  by  November  5th  fully  three-fourths  of  the 
urine  was  coming  from  the  umbilicus.  A  small  stream  came  from  the  urethra,  a 
large  one  from  the  umbilicus. 


APPARENT  ESCAPE  OF  URINE  FROM  THE  UMBILICUS,  THE  BREASTS,  AND  OTHER 

PARTS  OF  THE  BODY. 

The  accompanying  remarkable  case,  recorded  by  Lynker  in  1836,  is  difficult  to 
interpret.     I  have  found  no  similar  case  in  the  literature. 

Lynker*  reports  the  case  of  a  woman,  aged  twenty-four,  who  in  1831  had  a  bad 
fall  and  became  sick.  In  1833  she  had  paralysis  of  the  lower  extremities.  Later  she 
had  dysuria  and  passed  hardly  any  urine.  Her  breasts  swelled  up,  and  she  passed 
what  looked  like  urine  from  them,  then  from  the  umbilicus,  and  later  from  the  legs, 
the  rest  of  the  body  skin  meanwhile  being  dry.  She  had  marked  pain  and  swelling 
in  the  lower  abdomen. 

Up  to  the  time  of  writing  no  clue  as  to  the  cause  had  been  obtained.  The  patient 
was  still  alive. 

*  Lvnker:  Retention  d'urine  suiviede  1' excretion  de  ce  liquide  par  des  voies  inaccoutumees. 
Gaz.  mid.  de  Paris,  1836,  vii,  602. 


LITERATURE  CONSULTED  ON  ACQUIRED  URINARY  FISTULA  AT  THE  UMBILICUS. 
d'Auxiron:  Une  observation  sur  un  homme  qui  rend  ses  urines  par  le  nombril.    Jour,  de  med., 

Paris,  1766,  xxiv,  58. 
Bardeleben:  Lehrbuch  der  Chirurgie  und  Operationslehre,  1882,  iv,  223. 
Binnie,  J.  F.:  Development  of  the  Urachus.     Jour.  Amer.  Med.  Assoc,  1906,  ii,  109. 
Cadell,  F.:   Notes  on  a  Case  of  Umbilical  Urinary  Fistula.     Edinburgh  Med.  Jour.,  1878,  xxiv, 

Part  i.  221. 
Chapin,  E.:  A  Case  of  Open  or  Patent  Urachus.     North  Amer.  Jour,  of  Homoeopathy,  New  York, 

1897.  third  series,  xii,  286. 
Civiale,  J.:  Traite  de  l'affection  calculeuse,  Paris,  1838,  261. 
Florentin,  P.:  Fongus  de  l'ombilic  chez  le  nouveau-ne  et  chez  l'enfant.     These  de  Nancy,  1908-09, 

No.  22. 
Freer,  J.  A.:  Abnormalities  of  the  Urachus.     Annals  of  Surg.,  1887,  v,  107. 
Guisy,  B.:  Deux  cas  de  permeabilite  congenitale  de  l'ouraque.     Ann.  d.  mal.  d.  org.  genito-urin., 

1903,  xxi,  986. 
Jacoby,  M.:  Zur  Casuistik  der  Nabelfisteln.  Berlin,  klin.  Wochenschr.,  1877,  202. 
Kirrnisson:    Maladies  congenitales  de  l'ombilic.  Traite  des  mal.  chirurg.  d'origine  cong6nitale, 

Paris,  1898,  208. 

'  1  ue-Lasouree :    D'un  cas  particulier  ou  les  urines  sortaient  par  l'ombilic.  Jour,  de  m6d., 

Paris,  1811,  xxi,  124. 
Levie,  L. :  Een  geval  van  profluvium  urinaj  per  umbilicum  abs  uracho  patente  bij  een  volwassen 

persoon.     Nederlandsch.  Tijdschrift  voor  Geneeskunde,  1878,  xiv,  501. 
Lexer,  E.:  Ueber  die  Behandlung  der  Urachusfistel.     Arch.  f.  klin.  Chir.,  1898,  lvii,  73. 
Littre:    Sur  un  fcetus  extraordinaire.     Histoire  de  l'Academie  Royale  des  Sciences  de  Paris, 

Amsterdam,  1701,  27. 


ACQUIRED    URINARY    FISTULA    AT   THE    UMBILICUS.  619 

Lynker:    Retention  d 'urine  suivie  de  l'excretion  de  ce  liquide  par  des  voies  inaccoutumees.  Gaz. 

med.  de  Paris,  1836,  vii,  602. 
Monod,  J.:    Desfistules  urinaires  ombilicalesdues  a  la  persistance  de  l'ouraque.     These  de  Paris, 

1899,  No.  69. 
Petit,  J.  L.:  Traite  des  malad.  chirurg.,  Chap,  xi,  3.     Oeuvres  completes,  8°.     Limoges,  1S37. 
Raussin:  L'urine  rendue  par  le  nombril.     Mem.  de  l'Acad.  de  Chir.,  Paris,  1752,  iii,  10. 
Simon,  C:  Quels  sont  les  phenomenes  et  le  traitement  des  fistules  urinaires  ombilicales.    These 

de  Paris,  1843,  No.  80. 
Starcke:  Fall  von  Urachusfistel.  Deutsche  militararztliche  Zeitschr.,  1883,  xii,  211. 
Trogneux,  A.:  Contribution  a  l'etude  des  fistules  ombilico-vesicales.  These  de  Paris,  1897,  No.  129. 


CHAPTER  XXXVI. 

URACHAL  CONCRETIONS  AND  URINARY  CALCULI  ASSOCIATED 
WITH  URACHAL  REMAINS. 

Historic  sketch. 

Urachal  stones  or  concretions. 

Urinary  calculi  in  the  urachus. 

Removal  of  vesical  stones  through  the  umbilical  opening. 

Other  calculi  in  the  umbilical  region. 

Phillips,  in  an  article  in  Todd's  Cyclopaedia  of  Anatomy  and  Physiology  (1835), 
said  that  in  January,  1787,  Boyer  exhibited  a  bladder  taken  from  a  man  thirty-six 
years  of  age.  The  urachus  formed  a  canal  1^2  inches  long,  and  contained  12  urinary 
calculi  each  the  size  of  a  millet-seed.  It  was  demonstrated  that  this  canal  was  not 
a  vesical  sac  or  a  prolongation  of  the  vesical  mucous  membrane. 

In  1838  Civiale,  in  his  treatise  on  calculous  affections,  called  attention  to  the 
fact  that  the  anatomist  Colombus  had  observed  calculi  at  the  umbilicus.  Civiale 
refers  to  the  case  of  a  woman  coming  under  Hagendorn's  care,  who  had  a  very 
painful  abdominal  abscess  which  contained  two  calculi.  He  also  refers  to  Vallis- 
nieri,  who  spoke  of  stones  escaping  from  the  umbilicus.  In  Helwig's  case,  cited  by 
the  same  author,  a  woman  seventy  years  old  had  an  umbilical  abscess;  it  broke, 
and  several  stones  escaped,  one  of  which  weighed  15  grains.  In  another  case  a  man 
discharged  from  the  umbilicus  a  calculus  which  weighed  about  an  ounce  and  was 
as  large  as  a  pigeon's  egg.  Civiale  also  referred  to  cases  observed  by  Tolet, 
Rhodius,  and  Roesler.  The  stones  varied  from  the  size  of  the  kernel  of  an  olive  to 
that  of  a  hazelnut.     They  escaped  from  the  umbilicus. 

Simon,  in  1843,  mentioned  the  fact  that  calcareous  concretions  had  been  found 
along  the  course  of  the  urachus  and  had  also  escaped  through  the  umbilical  ring. 
He  said  that  Colombus,  Donatus,  Harder,  Bartholin,  and  Cruveilhier  had  reported 
such  cases.  ' 

Simon  said  that  Rhodius  and  Helwig  had  reported  cases  similar  in  character. 
In  the  case  of  Helwig's  patient,  a  man,  the  stone  was  the  size  of  a  pigeon's  egg. 

Concretions  or  calculi  escaping  from  the  umbilicus  may  originate  from  several 
sources.  They  may  be  formed  in  the  bladder  or  in  the  urachus,  which  communi- 
cates with  the  bladder,  and  where,  consequently,  urinary  salts  can  become  concen- 
trated, or,  again,  in  a  urachus,  that  is  completely  isolated  from  the  bladder.  Finally 
we  have  umbilical  concretions.  The  escape  of  gall-stones  from  the  umbilicus  has 
been  considered  elsewhere. 

Calculi  developing  in  a  urachus  communicating  with  the  bladder  are  identical  in 
their  composition  with  vesical  stones.  Those  developing  in  the  urachus,  when  no 
connection  exists  between  it  and  the  bladder,  are  very  small;  umbilical  concretions 
are  cheesy  in  character.  These  last  have  been  considered  in  detail  in  Chapter  XV 
(p.  247). 

The  majority  of  the  cases  mentioned  in  the  historic  sketch  just  given  are  not 

620 


CALCULI    ASSOCIATED    WITH    URACHAL    REMAINS.  621 

sufficiently  clear  to  enable  one  to  determine  with  any  degree  of  accuracy  to  which 
group  they  belong. 

URACHAL  STONES  OR  CONCRETIONS. 

The  careful  and  painstaking  investigations  of  Luschka,  published  in  1862,  give 
us  a  very  comprehensive  knowledge  of  the  urachus.  He  says  the  urachal  contents 
are  not  all  alike.  The  fluid  is  usually  pale  yellow,  thin,  and  translucent.  It  may, 
however,  be  cloudy,  and  brown  or  reddish  in  color.  It  contains  a  large  number  of 
cells,  numerous  fat-globules,  and  not  infrequently  corpora  amylacea.  In  the  dilata- 
tions and  in  the  isolated  cysts  the  contents  are  frequently  sticky  and  of  a  dirty  brown 
color,  and  scattered  throughout  the  field  are  bodies  which  have  a  marked  resem- 
blance to  prostatic  concretions. 

Urachal  concretions  were  also  described  by  Hoffmann  in  1870. 

Suchannek,  in  1879,  when  describing  the  contents  of  a  patent  portion  of  the 
urachus,  discussed  the  granular  bodies.  These,  he  said,  judging  from  their  reaction 
to  acetic  acid,  are  due  to  a  degeneration  of  the  epithelium,  which  is  probably  colloid 
or  amyloid  in  character. 

Wutz  briefly  details  his  findings  in  the  cyst  contents  of  the  many  cases  he 
examined. 

In  Case  11  he  noted  that,  a  short  distance  from  the  bladder,  the  urachus  con- 
tained an  oval  body  0.17  x  0.1  mm.  It  was  brownish  in  color  and  homogeneous  in 
consistence.  In  the  further  course  of  the  tube  were  several  diverticula  and  nipped- 
off  cysts  of  various  shapes.     They  contained  firm  brownish  contents. 

In  Case  15  Wutz  says  that  the  cysts  were  filled  with  lumps  of  brownish  and 
yellow  material. 

In  Case  17  the  cyst  contents  were  yellowish  white  and  friable. 

In  Case  18  Wutz  found  a  spindle-shaped  urachal  cyst,  2x1  mm.  Its  contents 
were  brownish  yellow  in  color. 

Wutz,  in  summing  up  his  observations  on  cyst-contents,  said  that  they  consisted 
of  fat-crystals,  fat-droplets,  free  fat,  large  flat  epithelial  cells,  brownish-yellow  amor- 
phous masses,  isolated  cholesterin  crystals,  and  small,  round,  very  glistening  bodies. 
In  one  of  the  cysts  in  Case  22  he  found  a  small,  firm,  stony  hard,  yellowish-brown, 
glistening  body.  Under  the  microscope  this  was  irregular,  nodular,\  and  partly 
transparent.  It  was  0.37  x  0.36  mm.  in  diameter.  On  the  addition  of  hydrochloric 
acid  free  carbonic  acid  escaped. 

Ledderhose  referred  briefly  to  urachal  concretions  in  1890. 

In  Boyer's  case,  which  we  have  already  considered  and  In  which  12  millet-seed- 
sized  stones  were  found  in  the  urachus,  these  bodies  were  urinary  stones. 

Rokitansky  (1861)  referred  to  a  case  in  which  21  calculi  the  size  of  linseeds  were 
found  in  a  urachal  dilatation  0.6  mm.  above  the  top  of  the  bladder. 

Veiel,  one  of  Luschka's  pupils,  in  his  dissertation  on  the  urachus  published  in 
1862,  described  his  findings  in  the  body  of  a  man  forty-five  years  old.  "Passing 
downward  in  the  mid-line  from  the  umbilicus  was  a  delicate  cord  1  mm.  broad.  Three 
centimeters  above  the  bladder  it  commenced  to  get  thicker,  and  at  the  bladder  was 
1.2  cm.  broad.  The  urachus  could  be  divided  into  four  sections.  The  lowest 
section,  situated  nearest  the  bladder,  was  14  mm.  long  and  patent.  The  next  was 
7  mm.  long,  solid,  and  thread-like.  The  third  was  8  mm.  long  and  was  also  patent. 
The  fourth  section— nearest  the  umbilicus— was  solid.     After  the  urachus  had  been 


622  THE   UMBILICUS   AND   ITS   DISEASES. 

treated  with  acetic  acid,  three  dilatations  of  the  canal  could  be  seen.  They  con- 
tained yellowish  concretions. 

Arrou,  in  1910,  in  an  article  entitled  A  Suppurating  Cyst  of  the  Urachus,  re- 
ported a  case  in  which  an  abscess  contained  a  stone  or  concretion  the  size  of  an  olive; 
it  was  like  a  piece  of  incompletely  dried  mortar.  [I  should  be  inclined  to  look  upon 
it  as  a  simple  umbilical  concretion  accompanied  by  inflammation,  were  it  not  for  the 
fact  that  the  lower  end  of  the  sac  bore  a  definite  relation  to  the  urachus. — T.  S.  C] 

Suppurating  Cyst  of  the  Urachus.  —  Arrou*  reports  the  case 
of  a  patient  operated  upon  by  Tricot.  A  soldier  with  absolutely  no  history  of  blad- 
der trouble  complained  of  vague  pain  in  the  umbilical  region.  The  pain  became 
acute,  and  the  patient  when  marching  had  to  bend  forward.  There  was  no  nausea 
and  no  intestinal  disturbance.     Urination  was  normal;  there  was  no  fever. 

Examination  revealed  a  painful  plaque,  as  large  as  the  palm  of  the  hand,  a  little 
below  the  umbilicus.  There  was  no  edema  or  redness.  Gradually  a  little  swelling 
was  noted  over  the  painful  area;  this  was  accompanied  by  some  fever. 

Operation. — An  exploratory  incision  was  made  under  the  supposition  that  there 
was  an  abscess  in  the  abdominal  wall,  but  when  the  patient  was  in  the  operating- 
room,  there  was  an  escape  of  a  small  amount  of  pus  from  the  lower  margin  of  the 
umbilicus.  A  probe  introduced  into  the  small  orifice  passed  downward  and  back- 
ward into  a  cavity,  measuring  6  cm.  in  its  vertical  direction.  The  patient  was  at 
once  anesthetized  and  the  cavity  incised.  It  proved  to  be  the  size  of  a  mandarin 
orange.  It  contained  a  calculus  the  size  of  an  olive,  that  was  like  a  piece  of  incom- 
pletely dried  mortar.  The  cyst  lining  resembled  an  inflamed  mucosa.  Unfortu- 
nately, both  sac  and  calculus  were  lost. 

The  upper  end  of  the  sac  ended  at  the  bottom  of  the  umbilicus.  The  lower 
extremity  terminated  in  a  closed  cul-de-sac.  Attached  to  the  lower  portion  of  the 
sac  was  a  large  cord,  the  size  of  the  little  finger,  which  became  smaller  and  termi- 
nated in  the  fundus  of  the  bladder.  Arrou  was  sure  that  it  was  the  urachus.  The 
peritoneum  was  opened  above  and  laterally.  The  intestines  were  protected  and 
the  urachus  was  cut  across  with  the  cautery  at  a  point  several  millimeters  above  the 
bladder.  The  sac  was  completely  removed  and  the  wound  closed.  The  patient 
made  a  good  recovery. 

From  the  data  at  hand  it  is  evident  that  urachal  concretions  or  stones  are  very 
rare.  They  are  usually  no  larger  than  linseed  grains  or  millet-seeds.  They  are 
usually  yellowish  brown  or  brown  in  color,  and  may  resemble  corpora  amylacea. 
They  are  too  small  to  be  a  surgical  factor,  and  are  of  interest  only  to  the  pathologist. 


URINARY  CALCULI  IN  THE  URACHUS. 
In  1877  Vosburgh  reported  his  observations  on  a  man  aged  fifty,  who  had  been 
complaining  of  a  soreness  and  constant  pain  at  the  navel.  Examination  showed 
redness,  tenderness,  and  a  hard  swelling  around  the  umbilicus.  The  tumor  was 
incised,  and  at  the  depth  of  half  an  inch  a  stone,  the  size  of  a  hickory-nut,  was  felt 
and  at  once  removed.  The  stone  was  phosphatic  in  character  and  had  a  strong 
urinary  odor.  The  wound  healed.  The  patient  stated  that,  about  twenty  years 
before,  a  stone  had  been  removed  in  a  similar  manner  from  this  location. 
*  Arrou:  Kyste  suppure  de  l'ouraque.     Bull,  et  Mem.  de  la  Soc.  de  chir.,  Paris,  1910,  xxxvi,  832. 


CALCULI    ASSOCIATED    WITH    URACHAL    REMAINS.  623 

Monod,  in  1899,  referred  to  the  stagnation  of  urine  in  the  interior  of  the  urachus 
as  giving  rise  to  calculi.  He  said  that  Colombus,  Marcellus,  Donatus,  Harder,  and 
Bartholin  had  cited  examples  of  this  kind.  He  added  that  the  calculi  may  be  elimi- 
nated through  the  umbilicus,  as  was  noted  by  Hagendorn,  Rhodius,  and  Hehvig. 

The  same  author  mentions  a  case  recorded  by  Peyer  in  1721,  in  which  a  calculus 
escaped  from  the  umbilicus  after  retention  of  urine.  In  the  chapter  on  Urachal 
Infections  I  have  referred  to  a  case  reported  by  Weiser  (p.  603).  The  patient,  a 
woman  seventy-five  years  of  age,  had  had  a  purulent  discharge  from  the  umbilicus 
for  fifteen  years.  When  Weiser  saw  her  she  had  a  tumor  the  size  of  a  cocoanut  situ- 
ated in  the  mid-line,  between  the  umbilicus  and  symphysis.  When  this  was  opened, 
five  ounces  of  very  fetid  pus  escaped,  and  also  a  calculus  weighing  70  grains.  The 
wound  healed  in  three  months.  Wishing  to  find  out  the  character  of  this  stone,  I 
wrote  Dr.  Weiser,  and  from  his  reply  it  appears  probable  that  it  closely  resembled  a 
vesical  calculus,  but,  as  noted  from  the  history,  there  was  no  opening  into  the  bladder 
and  no  urine  escaped  from  the  incision  during  the  patient's  convalescence. 

Probably  one  of  the  most  interesting  cases  is  the  one  recorded  by  Dykes.  It 
might  be  claimed  that  the  extravesical  portion  of  the  stone  developed  in  a  divertic- 
ulum of  the  bladder,  but  the  location  of  the  opening  in  the  top  of  the  bladder  and  in 
the  median  line  leaves  little  doubt  that  the  cavity  was  a  dilated  portion  of  the  ura- 
chus, especially  as  the  probe  in  the  cavity  could  be  carried  up  to  within  two  inches  of 
the  umbilicus. 

Patent  Urachus  and  Encysted  Urinary  Calculi.*  — 
"This  case,  which  both  in  its  clinical  and  pathologic  bearings  I  believe  to  be  of  some 
interest,  came  under  observation  on  January  27,  1908,  at  Rae  Bareli  Oudh: 

"The  patient  was  a  Hindu  male,  aged  about  thirty  years,  apparently  healthy 
apart  from  his  urinary  complaint,  which  dated  back  some  five  years  or  more.  Owing 
to  pressure  of  work  I  had  not  seen  him  until  he  was  on  the  operating  table,  prepared 
for  litholapaxy.  The  urine,  I  was  informed,  was  acid  and  free  from  albumin.  Sev- 
eral small  concretions  lay  free  on  the  base  of  the  bladder,  but  on  commencing  to 
crush  the  first,  the  beak  of  the  lithotrite  impinged  upon  what  appeared  to  be  a  much 
larger  calculus,  occupying  a  position  at  the  apex  of  the  half -distended  bladder.  After 
the  first  stone  had  been  crushed  the  projecting  portion  of  this  larger  calculus  was 
easily  seized  between  the  blades  of  the  lithotrite,  but  was  found  to  be  fixed  to  the 
bladder- wall. 

"To  crush  this  calculus  in  situ  appeared  dangerous,  if  not  impossible,  so  lateral 
lithotomy  was  performed  and  the  forefinger  passed  into  the  bladder.  The  calculus 
was  now  found  j  ust  within  reach  of  the  finger.  With  the  forefinger  on  the  tip  of  the 
calculus  and  the  other  hand  on  the  abdominal  wall,  it  was  estimated  to  be  of  con- 
siderable size,  and  its  upper  portion  seemed  very  close  under  the  examining  hand 
beneath  the  abdominal  wall  in  the  middle  line.  It  was  evidently  an  'hour-glass' 
stone,  the  deeper  half  being  considerably  larger  than  the  projecting  portion  felt  by 
the  finger.  The  projecting  portion  being  steadied  in  the  grasp  of  the  lithotomy 
forceps,  the  perforated  end  of  a  long  probe  was  insinuated  alongside  the  neck,  and 
gradually  manceuvered  around  the  whole  circumference,  loosening  the  retaining 
tissue,  until,  by  gentle  traction  and  rotation  of  the  forceps,  an  'hour-glass'  calculus 
was  safely  delivered.  A  second  calculus  immediately  dropped  from  the  same  pocket 
into  the  bladder  cavity.  It,  together  with  the  three  small  concretions,  the  presence 
*  Dykes,  Campbell:  The  Lancet,  1910,  i,  566. 


624  THE    UMBILICUS   AND    ITS   DISEASES. 

of  which,  on  the  bladder  floor,  had  already  been  detected,  was  now  removed,  and  the 
debris  of  the  small  stone,  first  crushed,  washed  out.  In  case  other  concretions  might 
still  be  lying  in  the  pocket  its  recesses  were  explored  with  a  probe.  Nothing  further 
was  found,  but  the  probe  passed  up  in  the  middle  line,  easily  palpable  through  the 
abdominal  wall,  to  a  point  two  inches  below  the  umbilicus.  At  the  upper  end  the 
pocket  seemed  to  be  contracted  to  a  mere  sinus.  Convalescence  was  rapid  and 
uncomplicated. 

"The  ' hour-glass '  calculus  weighed  over  l^  ounces.  Its  neck  was  of  about  the 
thickness  of  a  cedar  pencil,  but  somewhat  flattened.  The  deeper  lobe  was  larger 
than  the  projecting  head,  which  was  capped  by  a  pea-sized,  rough,  dark-colored 
concretion,  easily  broken  off,  when  drj",  from  the  head  proper.  This  terminal  con- 
cretion resembled  exactly,  in  color  and  approximately  in  size,  the  four  small  con- 
cretions which  had  been  found  free  in  the  bladder,  differing  only  in  being  rough  and 
not  polished  or  faceted  by  attrition.  This  resemblance  strongly  suggested  that 
these  four  also  owned  the  same  source,  from  the  head  of  the  '  hour-glass '  calculus. 
Each  weighed  about  10  or  12  grains.  The  second  encysted  calculus  showed  a  large 
oval  facet  corresponding  to  a  like  facet  on  the  base  of  the  'hour-glass'  calculus.  Its 
longer  axis  had  lain  at  right  angles  to  that  of  the  diverticulum  in  which  it  lay.  It 
weighed  just  over  half  an  ounce. 

''Neither  in  recorded  cases  nor  in  museum  specimens  have  I  come  across  any 
instance  in  which  an  encj^sted  calculus  had  occupied  the  apex  of  the  bladder.  All 
the  records  I  have  found  refer  to  basal  or  lateral  sacculi,  such  as  are  commonly 
associated  with  enlarged  prostate  and  chronic  cystitis.  This  is  so,  for  instance,  in 
all  the  cases  of  encysted  calculus  included  in  the  late  Sir  Henry  Thompson's  series  of 
over  800  cases,  the  specimens  of  which  are  now  in  the  museum  of  the  Royal  College 
of  Surgeons  of  England.  From  the  position  and  relations  of  the  diverticulum  this 
case  appears  to  be  an  example  of  persistent  patency  of  the  lower  end  of  the  urachus, 
with  calculus  formation  following,  presumably  on  the  accidental  lodgment  of  a  small 
concretion  in  it. 

"While  urachal  cysts  are  much  commoner  in  the  female  than  in  the  male,  a 
patent  condition  of  the  urachus  leading  to  urinary  umbilical  fistula  is  much  com- 
moner in  the  male." 

A  Patent  Urachus;  Vesical  Calculi;  Sac-like  Dilata- 
tions in  the  Urachus  Containing  Urinary  Calculi;  Re- 
moval of  All  the  Calculi;  Recovery.  —  During  the  meeting  of 
the  Southern  Surgical  and  Gynecological  Association  held  in  Cincinnati  on  Decem- 
ber 13,  1915,  the  President,  Dr.  Bacon  Saunders,  of  Fort  Worth,  Texas,  told  me  of 
the  following  interesting  case  that  came  under  his  care  several  years  ago. 

The  patient  was  a  boy  about  eleven  years  of  age.  He  had  had  all  the  classic 
symptoms  of  stone  in  the  bladder  since  infancy.  Examination  disclosed  a  fistulous 
opening  at  the  umbilicus  through  which  escaped  quantities  of  foul-smelling  urine. 
On  a  line  from  the  umbilicus  to  the  pubic  region  were  five  nodules  ranging  in  size 
from  a  hazelnut  to  an  almond. 

A  number  of  small  calculi,  resembling  prostatic  stones  were  removed  from  the 
bladder.  An  incision  was  made  over  each  of  the  nodules  in  the  mid-line  below  the 
umbilicus  and  a  stone  removed  from  each.  These  stones  were  of  the  same  char- 
acter as  those  found  in  the  bladder.  Urine  escaped  from  the  multiple  openings  for 
a  while,  but  these  openings  eventually  all  closed,  and  the  boy  made  a  satisfactory 
recovery. 


CALCULI    ASSOCIATED    WITH    URACHAL    REMAINS. 


625 


REMOVAL  OF  VESICAL  STONES  THROUGH  THE  UMBILICAL  OPENING. 

In  the  chapter  on  Congenital  Umbilical  Urinary  Fistula  (p.  507)  I  have  quoted 
the  well-known  case  of  Paget  and  Bowman.  The  patient,  John  Conquest,  an  iron 
founder,  forty  years  old,  had  had  a  urinary  fistula  at  the  umbilicus  since  birth. 
Paget  detected  a  stone  in  the  bladder.  The  umbilical  opening  being  rather  large,  he 
introduced  a  finger,  engaged  the  stone  in  the  urachus,  and  brought  it  out  through 
the  umbilicus.  This  stone  was  irregularly  ring-shaped,  having  developed  around  a 
curled-up  hair  (Fig.  221,  p.  507). 
It  was  by  getting  the  tip  of  his 
finger  into  the  central  hole  in  the 
stone  that  he  was  enabled  to  re- 
move it  by  this  route. 

Nicaise  refers  to  a  case  pub- 
lished by  Faivre  in  the  Journal  de 
mecl.  et  chir.,  1786.  The  patient, 
a  small  girl  of  twelve,  had  for  four 
years  passed  her  urine  from  the 
umbilicus.  The  urethra  was  ob- 
structed by  a  calculus.  Finally 
there  was  considerable  engorge- 
ment of  the  surface  of  the  abdo- 
men, due  to  the  urine  escaping 
into  the  cellular  tissue.  Faivre 
entered  the  bladder  through  the 
umbilicus  and  removed  the  stone. 
A  sound  was  introduced  into  the 
urethra,  and  the  child  made  a 
complete  recovery. 

If  urinary  calculi  develop  in 
the  urachus,  they  will  naturally 
be  found  near  the  bladder,  as  in- 
dicated in  Fig.  255. 


Fig.  255. — A  Patent  Urachus  Containing  a  Vesical  Cal- 
culus. (Schematic.) 
The  urachus  is  recognized  as  an  open  channel  from  the  upper 
part  of  the  bladder  to  the  umbilicus.  Just  above  the  bladder  it 
contains  a  spheric  and  rough  vesical  calculus.  In  the  upper  part 
of  the  umbilicus  is  a  small  umbilical  hernia. 


OTHER  CALCULI  IN  THE  UMBILI- 
CAL REGION. 

On  p.  337  we  have  discussed 
at  length  the  escape  of  gall-stones 
at  the  umbilicus.  The  following 
cases,  reported  by  Kostlin  and 
by  Bramann,  while  not  strictly  germane  to  the  subject,  are  of  considerable  interest. 

Communication  Between  the  Gall-bladder  and  the 
Urinary  Bladder,  With  Escape  of  Gall-stones  Through 
the  Urinary  Tract.  —  Kostlin*  cites  the  case  of  a  patient  whose  history 
Faber  had  already  reported  in  an  inaugural  dissertation.     This  woman  first  had 

*  Kostlin,    O.:    Verbindung  zwischen  Gallenblase  und  Harnblase,  mit  Abgang  von  Gallen- 
steinen  durch  die  Harnwege.     Deutsche  Klinik,  1864,  xvi,  116. 
41 


626  THE    UMBILICUS   AND    ITS   DISEASES. 

trouble  when  thirty-five  yea,vs  of  age.  In  the  autumn  of  1834  she  had  signs  of 
peritonitis,  with  pains  in  the  umbilical  region.  Later  the  pain  was  more  marked 
above  the  symphysis.  In  October,  1835,  she  was  again  ill,  this  time  with  broncho- 
pneumonia. On  the  fourth  day  there  was  pain  over  the  symphysis,  and  the  urine 
was  blackish  green  (bile).  The  patient  soon  passed  gall-stones,  large  and  small,  by 
the  urethra.  The  gall-stones  were  examined  chemically.  The  patient  was  kept 
under  observation  for  years.  She  died,  at  sixty-three,  with  symptoms  of  bron- 
chial catarrh  and  asthma. 

Autopsy. — The  liver  was  normal,  but  the  entire  organ  was  situated  lower  than 
usual.  From  the  middle  of  the  lower  edge  a  rounded  cord  extended  to  the  base  of 
the  bladder,  passing  in  front  of  the  intestine  and  pushing  the  transverse  colon  down- 
ward and  to  the  left.  The  cord  consisted  of  two  portions — the  lower  and  larger  half 
was  1"  7.6"'  (about  one  and  three-fourth  inches  long)  and  was  composed  of  the 
urachus.  The  upper,  shorter  half  belonged  to  the  lower  portion  of  the  gall-bladder. 
The  entire  length  of  this  was  3"  1.5"'  (about  3}4  inches  long).  The  route  which 
the  bile  and  gall-stones  traveled  was  from  the  gall-bladder  through  the  urachus 
to  the  urinary  bladder. 

Kostlin  mentions  a  similar  case,  reported  by  Pelletan.*  In  this  case  there  was 
no  autopsy. 

Probably  a  Distended  Gall-bladder  Opening  at  the 
Umbilicus.!  —  The  patient  was  a  single  woman,  sixty-three  years  of  age. 
She  had  had  typhoid  when  thirteen.  At  the  age  of  forty-five  she  had  had  sudden 
abdominal  pain,  accompanied  by  high  fever,  and  there  was  much  discomfort  in  the 
gall-bladder  region.  There  was  a  tendency  to  vomit,  and  the  abdomen  was  some- 
what swollen.  A  tumor  could  be  made  out  above  and  to  the  right  of  the 
umbilicus.  It  was  the  size  of  a  fist  and  painful.  The  tumor  persisted,  grew  slowly, 
and  tended  to  pass  more  and  more  downward  toward  the  symphysis. 

Two  years  later  a  large  quantity  of  foul  pus  escaped  from  the  umbilicus.  Pus 
continued  to  be  discharged  in  varying  amounts  from  the  umbilicus  for  about  sixteen 
years.     The  patient  was  otherwise  in  good  condition. 

On  admission  the  abdomen  was  found  to  be  slightly  distended.  The  skin  sur- 
rounding the  umbilicus  was  covered  with  crusts,  exfoliated  epithelium,  and  small 
cysts.  The  umbilicus  was  drawn  in,  and  in  its  center  was  a  small  discharging  fistula. 
The  escaping  pus  was  foul-smelling.  On  palpation  exactly  in  the  mid-line  a  long, 
egg-shaped  tumor  was  noted.  At  the  umbilicus  this  was  5  cm.  broad.  It  extended 
almost  to  the  symphysis,  and  in  its  lower  portion  it  was  7  to  8  cm.  wide.  The  tumor 
lay  distinctly  behind  the  abdominal  wall,  and  only  in  the  neighborhood  of  the  umbili- 
cus was  it  intimately  attached.  In  the  lower  part  it  was  somewhat  movable.  On 
pressure  it  was  found  to  be  of  dense  consistence.  A  sound  could  be  passed  12  cm. 
toward  the  symphysis  and  the  cavity  widened  out.  Calculi  were  detected  at  the 
bottom.     Urination  was  always  normal. 

Operation. — The  abdominal  wall  was  incised  for  8  cm.  from  the  umbilicus  down- 
ward. Four  faceted  calculi  the  size  of  pigeon's  eggs  were  removed,  and  the  tract  was 
curetted  out.  Healing  occurred  after  three  months,  but  in  the  mean  time  it  was 
necessary  to  curet  the  cavity  several  times.  After  several  vain  attempts  Bramann 
found  in  some  places  many  layers  of  squamous  epithelium. 

*  Pelletan:  Jour,  de  chimie  med.,  2.  ser.,  ii,  Nos.  11  et  12. 
t  Bramann,  F.:  Arch.  f.  klin.  Chir.,  1887,  xxxvi,  996. 


CALCULI    ASSOCIATED    WITH    URACHAL    REMAINS.  627 

Microscopic  examination  of  the  calculi  yielded  cholesterin  and  bile-pigment ;  no 
urinary  salts. 

[The  condition  might  well  be  explained  by  a  gall-bladder  extending  into  the  pelvis 
and  at  the  same  time  becoming  adherent  to  the  umbilicus.  Everything  points  to 
this  explanation,  although  Bramann  considered  the  case  to  be  one  of  open  urachus. 
— T.  S.  C] 


LITERATURE  CONSULTED  ON   URACHAL   CONCRETIONS   AND   URINARY  CALCULI 

ASSOCIATED  WITH  URACHAL  REMAINS. 
Arrou:  Kyste  suppure  de  l'ouraque.     Bull,  et  Mem.  de  la  Soc.  de  chir.,  Paris,  1910,  xxxvi,  832. 
Bramann,  F.:   Zwei  Falle  von  offenem  Urachus  bei  Erwachsenen.     Arch.  f.  klin.  Chir.,   1887, 

xxxvi,  996. 
Civiale,  J.:  Traite  de  l'affection  calculeuse,  Paris,  1838,  257. 

Dykes,  C:  Patent  Urachus  and  Encjrsted  Urinary  Calculi.    The  Lancet,  1910,  i,  566. 
Hoffmann,  C.  E.  E.:  Zur  pathologisch-anatomischen  Veranderung  des  Harnstrangs.    Arch,  der 

Heilkunde,  1870,  xi,  373. 
Kostlin,    O.:  Verbindung  zwischen  Gallenblase  und  Harnblase,  mit  Abgang  von  Gahensteinen 

durch  die  Harnwege.     Deutsche  Klinik,  1864,  xvi,  116. 
Ledderhose,  G.:  Chir.  Erkrankungen  des  Nabels.     Deutsche  Chirurgie,  1890,  Lief.  45  b. 
Luschka,  H.:  Ueber  den  Bau  des  menschlichen  Harnstranges.     Arch.  f.  pathologische  Anatoniie 

u.  Physiologie  u.  f.  klin.  Med.,  1862,  xxiii,  1. 
Monod,  J.:  Des  fistules  urinaires  ombilicales  dues  a  la  persistance  de  l'ouraque.     These  de  Paris, 

1899,  No.  62. 
Nicaise:   Ombilic.     Diet,  encyclopedique  des  sciences  medicales,  Paris,  1881,  2.  ser.,  xv,  140. 
Phillips,  B.:    Persistence  of  the  Urachus.     Todd's    Cyclopaedia   of   Anatomy  and   Physiology, 

1835,  i,  393. 
Rokitansky,  C:  Pathologische  Anatomie.     3.  Aufl.,  Wien,  1861,  hi,  372. 
Simon,  C:   Quels  sont  les  phenomenes  et  le  trait ement  des  fistules  urinaires  ombilicales.     These 

de  Paris,  1843,  No.  80. 
Suchannek,  H.:  Beitrage  zur  Kenntnis  des  Urachus.     Inaug.  Diss.,  Konigsberg,  1879. 
Veiel,  E. :   Die  Metamorphose  des  Urachus.     Diss.,  Tubingen,  1862. 
Vosburgh,  H.  D. :  Patent  Urachus  with  Calculus.     Medical  Record,  New  York,  1877,  606. 
Weiser,  W.  R.:  Cysts  of  Urachus.     Annals  of  Surg.,  1906,  xliv,  529. 
Worster,  J.:   Case  of  Vesico-abdominal  Fistula  of  Fourteen  Years'  Standing.     Medical  Record. 

1877,  xii,  196. 
Wutz,  J.  B.:  Ueber  Urachus  und  Urachuscysten.     Virchows  Arch.,  1883,  xch,  387. 


CHAPTER  XXXVII. 
MALIGNANT  CHANGES  IN  THE  URACHUS. 

Carcinoma  of  the  urachus. 

Historic  sketch. 

Symptoms. 

Report  of  cases. 
Sarcoma  in  the  urachal  region. 
An  extraperitoneal  abdominal  tumor. 

A  large  multilocular  carcinomatous  cyst  of  the  urachus;    secondary  growths  in  the  pelvis  (per- 
sonal observation). 
A  rare  umbilical  cyst. 

CARCINOMA  OF  THE  URACHUS. 

I  have  been  able  to  find  three  cases  of  carcinoma  of  the  urachus  recorded  in 
the  literature. 

Sex.  —  All  of  the  patients  were  men.  Two  of  the  patients  had  had  con- 
genital urinary  fistula?  at  the  umbilicus,  and  in  each  of  these  the  discharge  of  urine 
had  ceased  after  the  use  of  escharotics.  The  third  patient  also  evidently  had  a 
congenital  fistula,  as  he  gave  a  history  of  "moisture  at  the  umbilicus"  during 
childhood.     This  had  ceased  without  treatment. 

Age.  —  The  patients  were  twenty-five,  twenty-seven,  and  thirty-two  respect- 
ively, indicating  that,  when  carcinoma  of  the  patent  urachus  develops,  the  ma- 
lignant change  occurs  in  early  adult  life. 

Hoffmann  and  Fischer  gave  very  careful  and  full  histories  of  their  cases.  Hoff- 
mann's patient,  when  twenty-seven  years  of  age,  noted  a  raised  hardening  between 
the  umbilicus  and  symphysis.  It  was  the  size  of  a  goose's  egg,  non-painful,  and 
movable  from  side  to  side.  It  gradually  extended  toward  the  symphysis  and  right 
inguinal  region. 

Shortly  after  the  tumor  was  noticed  the  patient  experienced  pain  on  urination. 
At  times  the  urine  was  abundant,  at  times  it  came  drop  by  drop.  The  man  rapidly 
grew  weaker  and  lost  25  pounds  in  four  months.  When  Hoffmann  saw  him.  the 
umbilicus  presented  a  peculiar  radiating  appearance,  while  in  the  mid-line,  just  below 
the  umbilicus,  was  a  roundish,  nodular  tumor,  8  to  10  cm.  long,  adherent  to  the  um- 
bilicus and  very  painful.  After  the  patient  had  urinated  an  area  of  tympany  could 
be  elicited  between  the  tumor  and  the  symphysis.  On  account  of  tenesmus,  the 
patient  urinated  every  hour.  The  urine  contained  pus  and  aggregations  of  epithe- 
lial cells. 

The  tumor  became  fluctuant,  ruptured,  and  a  large  amount  of  purulent  and 
bloody  fluid  escaped,  but  the  growth  did  not  diminish  in  size.  From  time  to  time 
onion-like  balls  escaped  with  the  pus.  These  consisted  of  quantities  of  squamous 
epithelial  cells  that  had  become  agglutinated.  Precisely  similar  balls  escaped  in 
Fischer's  case. 

The  urethra  was  normal. 

628 


MALIGNANT    CHANGES    IN    THE    URACHUS.  629 

The  umbilical  opening  closed  temporarily,  but  soon  reopened,  and  in  the  late 
stages  of  the  disease  the  inguinal  glands  were  swollen. 

As  noted  in  the  autopsy  report,  the  cavity  between  the  umbilicus  and  bladder 
had  walls  1  cm.  thick.  Its  inner  surface  had  an  irregular,  ulcerated,  and  eaten-out 
appearance  (Fig.  256).  The  bladder-wall  had  been  involved  by  continuity,  and  also 
contained  secondary  nodules.     The  growth  was  a  squamous-cell  carcinoma. 

Fischer's  patient,  when  thirty-one  years  old,  first  noted  a  small,  hard  tumor  the 
size  of  a  pigeon's  egg  below  the  umbilicus.  Seven  or  eight  months  later  he  had  pain 
on  micturition,  and  noticed  a  sediment  in  the  urine.  The  nodule  was  incised  on  the 
supposition  that  it  was  fluctuant,  and  slimy,  necrotic  tissue  escaped.  The  tumor 
soon  grew  out  of  the  incision,  bled  a  great  deal,  and  finally  left  an  ulcerated  area,  the 
walls  of  which  were  raised  and  hard,  while  the  floor  consisted  of  hard  nodules.  From 
the  ulcerated  area  onion-like  balls  of  epithelial  cells  escaped. 

The  inguinal  glands  on  both  sides  became  swollen.  At  autopsy  the  bladder 
mucosa  showed  a  catarrhal  swelling,  but  no  involvement  by  the  malignant  growth. 
The  prostate  was  normal.  The  growth  was  a  carcinoma,  evidently  of  the  squamous- 
cell  type,  as  indicated  by  the  onion-like  balls. 

Death  in  these  cases  may  occur  from  gradual  weakening  as  a  result  of  the  dis- 
ease, or  from  a  perforation  of  the  growth  posteriorly  into  the  abdominal  cavity, 
causing  a  peritonitis.  The  occurrence  of  three  cases  of  carcinoma  of  the  urachus 
is  another  point  in  favor  of  the  early  removal  of  the  patent  urachus. 

In  the  future  cancer  of  the  urachus,  when  met  with,  will  undoubtedly  be  oper- 
ated on  early.  The  growth  can  be  given  a  relatively  wide  berth,  and  the  block  dis- 
section should  include  the  inguinal  glands  on  both  sides. 

Cases  of  Carcinoma  of  the  Urachus  Developing  Years  After  the  Closure  of  a 

Congenital  Patent  Urachus. 

Carcinoma  Evidently  D  e  v  e  1  o  p  i  n  g  F  r  o  m  Remains  of 
the  Urachus.  —  Fischer*  saw  this  patient  in  consultation  with  Hanuschke  in 
1874.  The  man,  thirty-two  years  of  age,  sought  treatment  on  account  of  an  ulcer 
of  the  umbilicus.  During  his  childhood,  when  voiding,  there  was  a  moisture  at  the 
umbilicus.  Later  these  symptoms  disappeared  and  there  was  never  any  trouble  with 
urination.  Early  in  1873  he  casually  noticed  below  the  umbilicus  a  hard  tumor  the 
size  of  a  pigeon's  egg.  This  gave  rise  to  no  symptoms.  It  gradually  grew,  and  seven 
or  eight  months  later  there  were  pain  and  a  burning  sensation  on  micturition  and  sedi- 
ment in  the  urine.  Toward  the  end  of  1873  he  consulted  a  physician.  The  diffi- 
culty in  urination  had  increased,  and  the  tumor  had  grown  markedly.  His  general 
condition  was  not  satisfactory.  Hanuschke  thought  that  the  tumor  was  soft,  and 
that  he  could  make  out  fluctuation.  Accordingly  he  made  an  incision,  and  puru- 
lent, slimy  masses  escaped — evidently  pieces  of  necrotic  tissue.  The  tumor  mass 
grew  out  of  the  incision  wound ;  it  very  soon  broke  down,  with  a  good  deal  of  bleed- 
ing, and  an  ulcer  resulted.  When  Fischer  saw  the  patient,  he  was  pale  and  weak, 
had  difficulty  in  micturition,  and  suffered  from  strangury.  The  ulcer  was  situated 
2  cm.  below  the  umbilicus,  and  formed  a  deep  crater,  which  was  heart-shaped.  Its 
walls  were  elevated,  hard,  and  extended  below  the  level  of  the  skin  about  4  cm.  Its 
greatest  breadth  was  8  cm.     Its  greatest  length,  7  cm.     The  floor  was  very  irregular 

*  Fischer:  Die  Eiterungen  im  subumbilicalen  Raume.  Volkmann's  Sammlung  klin.  Vor- 
trage,  n.  F.  No.  89  (Chir.  No.  24),  Leipzig,  1894,  519. 


630  THE    UMBILICUS   AND    ITS    DISEASES. 

and  covered  with  hard  nodules.  It  reached  a  depth  of  5  cm.  below  the  skin  sur- 
face. Surrounding  the  ulcer  the  tissue  was  hard.  On  pressure  there  escaped  a  thin, 
bloody,  foul-smelling  pus  from  the  ulcer,  and  there  were  also  portions  of  the  tumor 
forced  out  as  small  balls  suggesting  onions.  These  were  composed  of  quantities  of 
flat  epithelial  cells. 

The  urine  was  acid,  slightly  cloudy,  and  had  a  purulent  sediment.  The  inguinal 
glands  on  both  sides  were  swollen. 

Complete  removal  of  the  growth  was  impossible.  The  abdominal  walls,  how- 
ever, were  split  in  the  mid-line  as  far  as  the  symphysis,  and  beneath  the  muscle  thick, 
pork-like  tumor  masses  were  found  adherent.  As  much  of  the  tumor  as  possible 
was  removed,  and  the  cautery  was  employed.  The  patient  died  fourteen  days 
after  the  operation.  Microscopic  examination  of  the  tumor  mass  showed  it  to  be  a 
carcinoma.  At  autopsy  the  inner  surface  of  the  bladder  was  found  to  show  catarrhal 
swelling.  It  was  intact.  There  was  no  abnormality  in  the  prostate.  The  intestines 
were  normal. 

A  Patent  Urachus,  Closure;  Later  Carcinoma  of  the 
Urachus.*  —  This  case  was  also  mentioned  in  the  Deutsche  Klinik,  1864,  xvi, 
116.  The  patient  was  a  man,  twenty-eight  years  of  age,  who  had  a  urachal  fistula 
at  birth.  This  was  healed  with  escharotics.  Twenty-five  years  later  a  tumor 
developed  between  the  umbilicus  and  the  symphysis.  This  broke  and  discharged 
pus  and  later  urine.  The  autopsy  revealed  a  carcinoma  of  the  mucosa  of  the 
urachus,  which  had  perforated  into  the  umbilicus  and  into  the  bladder. 

A  Patent  Urachus  Partly  Closed  by  the  Use  of  Escha- 
rotics; Later,  Carcinoma  of  the  Urachus.  —  Hoffmannf  first 
reports  the  case  of  Hermann  R.,  in  which  there  was  an  enormous  sac  formation  and 
accumulation  of  fluid  outside  of  the  abdomen.  This  Hoffmann  attributed  to  a 
dilated  urachus. 

Hoffmann  reports  the  case  of  Alexander  Wanner,  a  postal  employee,  who 
was  born  in  1841  with  an  opening  at  the  umbilicus  through  which  urine 
escaped,  while  it  also  passed  from  the  urethra.  This  condition  lasted  until 
his  third  year,  when  the  opening  closed  after  the  use  of  escharotics.  The 
patient  had  no  further  difficulty,  and  with  the  exception  of  several  inflam- 
mations of  the  eye  was  perfectly  well.  About  the  middle  of  the  year  1868 
he  noticed  between  the  umbilicus  and  the  symphysis,  near  the  umbilicus,  a 
raised  hardening  of  the  abdomen  about  the  size  of  a  goose's  egg,  which  was 
not  painful  and  could  be  pushed  from  side  to  side.  This  gradually  grew  and 
extended  toward  the  symphysis,  and  spread  toward  the  right  inguinal  region. 
Shortly  after  the  appearance  of  the  tumor  the  patient  began  to  have  pain  on  urina- 
tion. The  urine  sometimes  came  in  an  abundant  stream;  at  other  times  only  in 
drops.  As  a  result  the  patient  had  a  continuous  desire  to  urinate.  The  pains 
became  severe  and  he  grew  weaker.  He  had  lost  weight — in  the  last  four  months, 
25  pounds.  On  admission  to  the  hospital,  November  10,  1868,  he  weighed  99 
pounds,  was  poorly  nourished,  anemic,  and  had  a  peculiar  radiating  formation 
of  the  umbilicus,  in  the  folds  of  which  no  opening  could  be  discovered.  Immediately 
below  the  umbilicus  was  a  tumor,  8  to  10  cm.  long,  situated  in  the  middle  line.     It 

*  Graf,  Fritz:   Urachusfisteln  und  ihre  Behandlung.    Inaug.  Diss.,  Berlin,  1896. 
t  Hoffmann:    Zur    pathologisch-anatomischen    Veranderung   des   Harnstrangs.      Arch.    d. 
Heilkunde,  1870,  xi,  373. 


MALIGNANT   CHANGES   IN   THE    URACHUS.  631 

was  roundish,  nodular,  very  painful,  and  adherent  to  the  umbilicus,  but  on  both 
sides  it  was  free.  After  urination,  between  the  tumor  and  the  symphysis  was  an 
area  of  tympany.  On  account  of  the  tenesmus  the  patient  urinated  every  hour, 
and  the  urine  contained  pus  and  aggregations  of  epithelial  cells.  The  patient  drank 
quantities  of  soda-water  and  local  applications  were  made.  His  pain  diminished, 
but  the  tumor  continued  to  grow.  The  umbilicus  became  prominent,  fluctuation 
was  detected,  and  on  December  1st  the  swelling  broke  and  a  large  quantity  of 
thick,  purulent,  bloody  fluid  escaped.  The  tumor,  however,  did  not  diminish  in 
size,  although  the  pain  became  less  and  less.  In  the  fluid  numerous  onion-like 
balls  were  found.  These  consisted  of  large  quantities  of  squamous  epithelial  cells 
which  had  become  agglutinated. 

Examination  of  the  urethra  with  a  bougie  yielded  nothing  abnormal.  The 
prostate  was  not  enlarged,  the  bladder-wall  was  thick  and  did  not  contract  com- 
pletely after  the  escape  of  urine.  From  September  4th  urine  and  purulent  fluid 
often  escaped  from  the  umbilicus,  and  the  urine  passed  from  the  bladder  from 
that  time  on  was  cloudy.  The  opening  at  the  umbilicus  gradually  contracted,  and 
for  some  time  only  purulent  fluid  escaped  from  it.  The  tumor  became  smaller,  and 
toward  the  middle  of  January,  1869,  the  umbilicus  closed  completely. 

Diarrhea  developed  and  marked  emaciation.  At  the  end  of  January  the  open- 
ing at  the  umbilicus  reappeared,  and  a  purulent-like  material  escaped.  The  pain 
became  more  severe.  The  inguinal  glands  were  swollen  and  the  patient  grew  weaker. 
On  January  31st  he  weighed  88  pounds.     He  died  in  the  middle  of  May,  1869. 

Only  an  incomplete  autopsy  could  be  obtained.  The  family  physician  who 
made  it  said  there  were  appearances  of  peritonitis.  The  umbilicus  had  a  peculiar, 
radiating,  stellar  appearance,  and  there  was  an  opening  3  mm.  in  diameter.  Through 
this  there  was  a  passage  going  downward  and  backward  into  a  canal  which  grad- 
ually widened.  The  cavity  had  walls  1  cm.  thick.  It  extended  from  the  umbilicus 
to  the  top  of  the  bladder.  It  was  10  cm.  in  length,  and  in  its  middle  portion  was 
2.5  cm.  broad.  The  entire  inner  surface  presented  an  ulcerated,  irregular,  much 
eaten-out,  reddish  appearance  (Fig.  256). 

At  its  lower  part  this  cavity  communicated  with  the  bladder  by  an  opening 
3.3  cm.  broad,  and  the  posterior  wall  of  the  bladder  was  invaded  by  this  ulcerated 
growth  over  an  area  4  cm.  in  diameter.  The  bladder-walls,  where  invaded,  were 
1.8  cm.  thick,  while  the  unchanged  portions  were  0.8  cm.  thick.  At  the  point 
where  the  cavity  communicated  with  the  bladder  posteriorly  was  a  perforation,  the 
exact  size  of  which  could  not  be  determined  on  account  of  the  tearing  of  the  speci- 
men. The  bladder  mucosa,  on  the  whole,  looked  normal,  but  at  one  point  in  the 
anterior  wall  was  a  round  nodule,  1  cm.  in  diameter;  in  the  posterior  wall  were 
several  smaller  ones. 

Microscopic  examination  showed  that  the  growth  of  the  urachus  was  a  squamous- 
cell  carcinoma,  and  that  the  secondary  nodules  were  also  carcinomatous. 

Hoffmann  says  that  this  patient  was  born  with  a  patent  urachus.  The  opening 
at  the  umbilicus  had  closed  after  the  use  of  escharotics  in  the  third  year.  In  the 
twenty-seventh  year  a  carcinoma  developed  in  the  urachus  and  extended  to  the 
bladder.     The  perforation  caused  by  the  cancer  led  to  a  local  peritonitis. 

A  Urachal  Cyst  and  Cancer  of  the  Bladder  Occurring 
Independently.  — ■  Rotter's  case  may  well  be  considered  here.     The  urachus 


632 


THE    UMBILICUS    AND    ITS    DISEASES. 


J- 'ig.  256. — Carcinoma  of  the  Patent  Ubachus.     (After  C.  E.  E.  Hoffmann.) 
A  is  a  partially  diagrammatic  picture:  ",  The  anterior  abdominal  wall;  b,  the  opening  of  the  urachus  at  the  umbili- 
be  urachus,  which  is  occupied  by  a  carcinoma;  at  d  the  growth  has  broken  through  into  the  abdominal  cavity; 
< ,  the  bladder.    At  points  /,  /,  /,  /,  on  the  bladder  mucosa  are  small  secondary  carcinomatous  masses.     B  represents  the 
appearance  of  the  umbilicus  with  the  opening  of  the  urachal  fistula  in  its  center. 


MALIGNANT    CHANGES    IN    THE    URACHUS.  633 

was  the  seat  of  a  cyst  and  the  bladder  showed  a  carcinoma.  The  one  was  abso- 
lutely independent  of  the  other. 

Rotter's*  patient  was  a  forty-three-year-old  man,  who,  for  nine  months,  had 
had  bleeding  from  the  bladder.  Cystoscopic  examination  showed  a  tumor  in  the 
upper  portion  of  the  bladder.  This  did  not  grow  rapidly.  Above  the  symphysis, 
and  reaching  to  the  umbilicus,  was  another  tumor,  which  on  aspiration  yielded  a 
fluid  containing  cholesterin.  This  tumor  was  diagnosed  as  a  urachal  cyst.  At 
operation  the  upper  tumor  was  found  lying  between  the  peritoneum  and  the  abdom- 
inal muscles.  In  its  upper  portion  it  was  free,  but  over  the  lower  half  it  was  so 
intimately  blended  with  the  peritoneum  that  it  was  necessary  to  remove  a  portion 
of  the  peritoneum  with  the  tumor.  The  urachal  tumor  pressed  so  into  the  bladder 
muscle  that  it  was  also  necessary  to  open  this  viscus. 

The  cancer  of  the  bladder  was  removed,  and  a  defect  7  by  8  cm.  in  the  bladder 
closed  by  layers.  This  patient  was  shown  by  Rotter  at  the  Berlin  Surgical  Society. 
Microscopic  examination  demonstrated  carcinoma  of  the  bladder.  This  had  per- 
forated at  the  point  where  the  cyst  was  found.  The  cyst  contained  many  poly- 
morphous epithelial  cells.     There  was  no  doubt  that  it  was  a  urachal  cyst. 

Possibly  an  Adenocarcinoma  of  the  Urachus.  — I  am  at 
a  loss  where  to  place  this  case  of  Koslowski's.f  The  situation  of  the  tumor  sug- 
gests a  urachal  growth.  Furthermore,  the  variation  in  the  size  of  the  glands  might 
very  readily  correspond  to  the  cyst-like  spaces  we  have  noted  where  isolated  seg- 
ments of  the  urachus  have  persisted.  The  invasion  of  the  rectus  sheath  and  of  the 
rectus  muscle  naturally  points  toward  malignancy.  We  shall  accordingly  leave  this 
case  among  those  of  carcinoma  of  the  urachus.  Whether  it  really  belongs  here  or 
not  is  problematic. 

The  patient  was  a  man,  fifty-five  years  of  age,  who  five  weeks  before  had  noticed 
in  the  mid-line,  between  the  symphysis  and  the  umbilicus,  a  small,  painful  tumor 
which  grew  to  the  size  of  a  walnut.  This  man  was  markedly  emaciated,  looked  to 
be  seventy  years  of  age,  had  frequent  diarrhea,  and  was  bent  over  from  guarding 
the  abdominal  muscles.  Between  the  umbilicus  and  symphysis,  near  the  mid-line, 
was  a  tumor  which  suggested  a  patella.  The  overlying  skin  was  free.  The  tumor 
was  slightly  movable  and  very  painful.  It  felt  very  tense,  and  gradually  merged 
into  the  surrounding  tissue.  Passing  from  the  tumor  toward  the  umbilicus  was  a 
cord  the  size  of  a  goose-quill.  Koslowski  thought  the  tumor  was  a  malignant 
epithelial  growth  developing  from  remains  of  the  urachus. 

Operation. — A  median  incision  showed  that  the  linea  alba  and  sheath  of  the 
rectus  had  been  penetrated  by  the  tumor.  An  elliptic  incision  encircled  the  umbil- 
icus and  the  tumor.  Removed  with  the  tumor  were  portions  of  the  sheath  of  the 
recti  and  some  of  the  rectus  muscle,  the  transversalis  fascia,  and  peritoneum.  After 
the  abdomen  was  opened,  the  tumor  was  drawn  up  and  brought  into  view  fibrous 
cords  passing  to  the  umbilicus.  The  upper  cord  was  the  size  of  a  goose-quill,  firm, 
and  infiltrated.  The  lower  cord  was  less  firm  and  contained  veins;  these  passed 
into  the  vesico-umbilical  ligament.  The  peritoneum  covering  the  posterior  surface 
of  the  tumor  showed  evidence  of  scar  and  of  ulceration.  The  patient  made  a  good 
recovery.     The  tumor  in  form  resembled  a  patella.     The  peritoneum  was  firmly 

*  Rotter:  Blasencarcinom  combinirt  mit  Urachuscyste.     Centralbl.  f.  Chir.,  1897,  xxiv,  604. 
t  Koslowski,  B.  S.:   Ein  Fall  von  wahrem  Nabeladenom.     Deutsche  Zeitschr.  f.  Chir..  1903, 
lxix.  469. 


634  THE    UMBILICUS    AND    ITS   DISEASES. 

attached  to  it.  The  surrounding  muscle  was  penetrated  by  the  tumor.  Micro- 
scopic examination  showed  that  it  was  made  up  of  glands  of  various  sizes.  They 
varied  from  the  size  of  urinary  tubules  to  those  large  enough  to  be  noted  with  the 
naked  eye.  The  diagnosis  was  fibro-adenoma  submalignum.  The  glands  resembled 
intestinal  glands. 

[It  is  difficult  to  establish  the  exact  character  of  this  tumor. — T.  S.  C] 


SARCOMA  IN  THE  URACHAL  REGION. 

Frank,  in  1893,  recorded  a  very  interesting  case  of  sarcoma  probably  developing 
in  the  sheath  of  the  urachus  in  a  young  lad.  Unfortunately,  the  subsequent  history 
of  the  case  is  lacking,  but  the  histologic  picture  of  the  growth,  the  invasion  of  the 
muscles  of  the  abdominal  wall,  and  the  secondary  nodules  in  the  omentum  leave 
no  doubt  as  to  its  malignancy. 

Alban  Doran  reports  a  case  of  sarcoma  developing  in  the  wall  of  a  cyst  of  the 
urachus.     This  is  so  interesting  that  I  shall  also  record  it  in  detail. 

Sarcoma  Probably  Developing  in  the  Sheath  of  the 
Urachus.  —  Frank*  gives  a  good  resume  of  the  literature  and  reports  the 
case  of  a  boy  eleven  years  of  age.  For  several  weeks  he  had  had  loss  of  appetite 
and  was  losing  weight.  About  fourteen  days  before  the  boy  came  under  observa- 
tion the  father  noticed  a  swelling  in  the  umbilical  region,  and  from  a  small  opening 
at  the  umbilicus  a  little  pus  could  be  pressed.  There  was  no  urinary  difficulty  and 
no  discomfort  on  defecation.  The  urine,  however,  had  recently  became  cloudy  and 
stringy.  The  child's  mother  had  died  of  pulmonary  disease,  otherwise  the  family 
history  was  good. 

On  examination  the  boy  was  found  to  be  strong  and  well  nourished.  In  the 
umbilical  region  was  a  hard,  circumscribed  thickening,  only  slightly  painful  on 
pressure,  reaching  about  a  fingerbreadth  above  the  umbilicus.  Here  it  could  be 
traced  three  fingerbreadths  to  the  right  and  to  the  left  of  the  linea  alba.  Below 
it  extended  almost  to  the  symphysis.  The  skin  over  the  tumor  was  only  slightly 
movable.  A  sound  introduced  into  the  sinus  passed  from  4  to  6  cm.  downward. 
With  a  sharp  curette  friable,  sanguineopurulent  masses  were  removed.  These  on 
examination  were  found  to  consist  of  pus-cells,  granulation  tissue,  and  debris. 

Operation. — An  elliptic  incision  was  made,  commencing  3  cm.  above  the  umbil- 
icus. The  recti  muscles  at  the  umbilicus  were  found  to  be  infiltrated  by  the  growth. 
The  incision  was  then  carried  through  healthy  muscle  to  the  peritoneum.  Loops 
of  small  bowel  were  adherent  to  the  peritoneal  surfaces  of  the  tumor,  and  nodules 
were  found  scattered  throughout  the  omentum.  The  tumor  was  gradually  turned 
out  ward  and  was  removed  without  much  difficulty.  Its  lower  end  was  intimately 
adherent  to  the  bladder,  and  the  outer  walls  of  this  viscus  were  removed  and 
the  small  opening  in  it  was  closed.  The  omentum  was  removed  on  account  of 
the  tumor  nodules.  The  abdomen  was  closed  with  difficulty.  The  patient's 
recovery  was  slow. 

The  tumor,  on  section,  was  found  to  have  invaded  the  recti  in  all  directions. 
Its  chief  extension  was  along  the  course  of  the  urachus  as  far  as  the  bladder.  The 
tumor  itself,  with  the  surrounding  parts,  was  as  large  as  a  man's  fist,  and  was  nod- 
ular and  uneven. 

*  Frank,  Theodor:   Zur  Casuistik  der  Urachustumoren.     Inaug.  Diss.,  Wurzburg,  1893. 


MALIGNANT   CHANGES    IN    THE    URACHUS.  635 

On  microscopic  examination  the  sarcomatous  character  of  the  tumor  was  evi- 
dent. In  the  center  of  the  tumor  the  intercellular  substance  was  most  marked,  but 
toward  the  periphery  it  consisted  almost  entirely  of  spindle-cells  with  little  con- 
nective tissue.  The  growth  of  the  spindle-cells  into  the  recti  and  into  the  bladder 
was  especially  evident.  The  entire  picture  indicated  that  the  tumor  had  developed 
in  the  connective-tissue  layers  of  the  urachus  and  that  it  had  then  spread  out  in  all 
directions. 

The  case  is  perfectly  clear,  but  there  is  no  after-history  beyond  two  months,  and 
no  description  of  the  omental  nodules. 

AUniqueSpecimenofCystic  Sarcomaof  the  Urachus.* 
— Alban  Doran  says:  "Mr.  F.  S.  Eve  has  presented  to  the  Museum  of  the  Royal 
College  of  Surgeons  of  England  a  unique  specimen  of  cystic  sarcoma  of  the  urachus, 
and  has  kindly  supplied  me  with  the  following  notes : 

' '  A  man,  aged  thirty-eight  years,  was  admitted  into  the  London  Hospital  with 
a  swelling  in  the  hypogastrium  noticed  for  several  weeks  and  associated  with  pain 
after  micturition.  A  cystic  tumor  filled  the  lower  part  of  the  abdomen,  especially 
to  the  right,  where  it  extended  toward  the  loin.  It  did  not  dip  into  the  pelvis. 
On  puncture,  dark  blood  came  away;  a  few  days  later  a  rigor  occurred,  with  vomit- 
ing and  a  rise  of  temperature  to  104°  F.  Mr.  Eve  then  operated,  exposing  a  large 
cystic  tumor;  the  parietal  peritoneum  was  reflected  over  its  anterior  and  superior 
surfaces.  Five  pints  of  dark,  bloody  material  were  removed.  The  cyst  adhered  to 
the  omentum,  which  bore  engorged  veins,  and  to  an  inch  and  a  half  of  small  intes- 
tine which  was  infiltrated  where  adherent.  The  adherent  portion  of  the  wall  of  the 
gut  was  excised,  and  the  wound  closed  with  sutures.  The  lower  part  of  the  cyst 
was  intimately  connected  with  the  bladder,  the  serous  coat  of  which  organ  was 
reflected  onto  its  surface.  This  peritoneal  covering  was  divided,  and  the  cyst  care- 
fully dissected  away  from  the  bladder.  During  the  process  the  bladder  was  opened, 
for  the  vesical  wall  at  this  point  was  so  thin  that  the  cavities  of  the  cyst  and  the 
bladder  were  only  separated  by  the  vesical  mucous  membrane  covered  by  a  few 
muscular  fibers.  The  opening  was  sutured,  but  not  without  great  difficulty,  owing 
to  the  thinness  of  the  walls  at  this  point.  The  sutures  were  further  protected  by 
gauze  packing.  A  gauze  drain  was  passed  into  the  pelvis,  and  a  catheter  retained 
for  a  while  in  the  bladder.  Neither  flatus  nor  feces  could  be  made  to  pass  after  the 
operation,  and  the  patient  died  on  the  fourth  day.  There  was  no  general  peri- 
tonitis, but  the  pelvic  peritoneum  had  become  inflamed  at  the  point  where  the 
gauze  had  been  applied.' 

"Mr.  Eve  examined  the  specimen  and  found  that  it  was  a  large  allantoic  cyst 
separated  from  the  posterior  superior  surface  of  the  bladder  by  nothing  except  a 
very  much  thinned  mucous  membrane.  Their  cavities,  however,  did  not.  com- 
municate. The  inner  wall  of  the  cyst  was  lined  at  certain  points  with  very  vascular 
polypoid  masses,  which  proved  to  be,  on  microscopic  examination,  sarcomatous. 
The  most  unusual  feature  of  this  cyst  was  its  malignancy,  but  its  peritoneal  rela- 
tions were  of  greater  importance  in  respect  to  the  subject  of  this  communication." 


AN  EXTRAPERITONEAL  ABDOMINAL  TUMOR. 
The  following  interesting  case,  the  specimen  from  which  was  exhibited  by  Dr. 
Aveling,  may  be  considered  here,  although  from  the  description  one  could  not  say 
*  Doran,  Alban  H.  G.:  The  Lancet,  1909,  i,  1304. 


636  THE    UMBILICUS    AND    ITS    DISEASES. 

that  the  growth  was  a  sarcoma.  It  may  serve,  however,  to  form  the  nucleus  around 
which  similar  cases  may  be  collected. 

Dr.  Aveling*  exhibited  before  the  British  Gynecological  Society  a  subperito- 
neal tumor  which  had  grown  in  the  anterior  abdominal  wall  and  reached  from  two 
inches  above  the  umbilicus  to  the  pubes.  It  was  removed  after  death,  the  patient 
having  succumbed  after  an  exploratory  operation.  Sir  Spencer  Wells,  who  saw  the 
tumor,  said  he  had  seen  only  two  similar  cases,  and  he  classified  the  tumor,  accord- 
ing to  Virchow,  as  a  fibroma  molluscum  cysticum  abdominale.  The  specimen  was 
referred  to  Mr.  Bland-Sutton  and  Dr.  Aveling  for  further  examination. 

The  tumor  was  ovoid  in  shape,  and  measured  10  inches  in  length,  7  inches  in 
width,  and  weighed  4%  pounds.  It  was  surrounded  by  a  distinct,  thick,  fibrous 
capsule.  On  section  the  tissue  was  of  a  dirty  white  color,  and  the  cut  surface 
looked  like  a  sponge.  The  loculi  were  filled  with  gelatinous  tissue,  which  readily 
broke  down  on  scraping  the  cavities  with  the  handle  of  a  scalpel.  Inside  the  growth 
six  or  seven  hard  nodules,  of  the  size  of  walnuts,  could  be  felt.  These,  when  dis- 
sected out  and  divided,  looked  like  small  leiomyomata,  such  as  occasionally  exist 
in  the  uterus.  They  presented  the  same  whorled  arrangement  of  the  fibers,  and 
corresponded  with  them  histologically.  On  microscopic  examination  of  the  tumor 
the  outer  portion  was  found  to  consist  of  non-striped  muscle-fibers,  some  of  large 
size.  Internal  to  this  the  cells  assumed  more  the  shape  and  characters  of  those 
seen  in  spindle-cell  sarcomata,  while  the  gelatinous  material  contained  in  the  loculi 
was  the  result  of  mucoid  degeneration  of  the  sarcomatous  elements. 

Sutton  and  Aveling  then  go  on  to  say  that  the  specimen  was  of  great  interest 
from  an  etiologic  standpoint.  "Man,  in  common  with  other  mammals,  possesses 
a  persistent  pedicle  of  the  allantois,  familiar  under  the  name  of  the  urachus.  This 
structure  is  frequently  found  dilated  into  a  cyst,  usually  of  small  size.  An  account 
of  these  allantois  cysts,  with  reference  to  a  few  recorded  cases,  will  be  found  in  the 
Path.  Soc.  Trans.,  xxxvi,  523."  They  drew  attention  to  the  fact  that  Mr.  Lawson 
Tait,  in  his  work  on  Diseases  of  the  Ovaries,  had  described  certain  growths  which 
he  regarded  as  probably  originating  in  the  urachus,  and  which  attained  such  con- 
siderable dimensions  as  to  require  operative  interference. 

They  thought  that,  in  the  present  case,  they  had  to  deal  with  an  allantois  cyst, 
the  walls  of  which  had  become  sarcomatous,  thus  affording  another  illustration  of 
the  great  tendency  exhibited  so  often  by  aberrant  and  ill-developed  structures  to 
become  the  seat  of  morbid  growths,  such  as  sarcoma  or  carcinoma. 

[After  a  somewhat  careful  study  of  the  literature  on  the  subject  of  umbilical 
tumors,  the  interpretation  of  Bland-Sutton  and  Aveling  is  not  altogether  clear.  It 
would  rather  seem  as  if  we  are  dealing  with  a  myoma.  The  gross  description  speaks 
of  non-striped  muscle,  and  this  the  histologic  picture  substantiates.  The  gross  and 
histologic  appearance  of  the  nodule  coincides  with  the  appearances  presented  by 
uterine  myomata.  The  areas  that  were  supposed  to  be  sarcomatous  and  inclosed 
cavities  presenl  ing  a  m  ucoid  appearance  might  very  readily  have  been  due  to  hyaline 
degeneration.  Without  an  opportunity  of  examining  their  specimen  we  should  hesi- 
tate to  express  any  definite  opinion  as  to  this  case,  further  than  that  their  interpreta- 
tion does  not  seem  to  tally  with  the  recorded  cases  of  secondary  growths  attributed 
to  the  allantois. — T.  S.  C] 

Doran*  says  that  Aveling  and  Bland-Sutton  had  already  reported  a  case  of 

*  Aveling:   Brit.  Gyn.  Jour.,  1886-87,  ii,  56  and  187. 
t  Doran,  Alban  H.  G. :  The  Lancet,  1909,  i,  1304. 


MALIGNANT    CHANGES    IN    THE    URACHUS. 


637 


multilocular  myxosarcoma  of  the  sheath  of  the  urachus,  but  it  did  not  involve  the 
urachal  canal,  and  was  quite  unconnected  with  the  bladder.  The  specimen  (No. 
417  b)  in  the  pathologic  series  of  the  Museum  of  the  Royal  College  of  Surgeons  of 
England  was  supposed,  when  first  examined,  to  have  developed  in  the  urachus,  but 
Mr.  J.  H.  Targett  considered  that  it  was  a  myxosarcoma  which  had  originated  in 
the  connective  tissue  surrounding  the  bladder. 

After  I  had  made  my  comment  on  Aveling  and  Bland-Sutton's  case,  Alban 
Doran's  note  on  the  case  came  to  my  notice,  clearly  showing  a  lack  of  unanimity 
of  opinion  among  those  who  had  examined  the  specimen,  not  only  as  to  the  exact 
character  of  the  tumor,  but  also  as  to  its  precise  source  of  origin. 


Multilocular    urachus  cvsi 


Omentum,  adherent" 
to  tumor 


Fig.  257. — A  Multilocular  and  Malignant  Cyst  of  the  Urachus. 
Gyn.-Path.  Nos.  10368  and  1048S.  The  cyst  lay  between  the  abdominal  muscles  and  the  peritoneum  of  the 
anterior  abdominal  wall.  Below  it  was  attached  by  a  pedicle  near  the  top  of  the  bladder.  Upward  it  extended  for 
a  considerable  distance  above  the  umbilicus.  The  omentum  was  densely  adherent  to  its  upper  surface.  The  cyst -wall 
anteriorly  was  so  thin  that  I  cut  it,  thinking  that  it  was  peritoneum.  The  cyst  is  composed  of  one  large  and  many 
smaller  cavities.  Projecting  into  the  large  cyst  are  many  smaller  cysts,  and  papillary  and  solid  growths  spring  from  the 
inner  surface  of  the  cyst.  Some  of  the  smaller  cysts  have  smooth  walls,  as  is  well  seen  in  the  one  near  the  pedicle  of  the 
tumor.  Cross-sections  of  other  small  cysts  show  that  they  are  partially  filled  with  secondary  growths.  It  will  be 
noted  that  the  uterus,  tubes,  and  ovaries  are  absolutely  independent  of  the  cystic  tumor.  They  are,  however,  partially 
covered  over  with  secondary  cancerous  nodules.      (For  the  histologic  appearances  in  this  case  see  Figs.  261,  262,  263.) 


A  LARGE  MULTILOCULAR  CARCINOMATOUS  CYST  OF  THE  URACHUS;  SECONDARY 

GROWTHS  IN  THE  PELVIS. 

I  saw  Mrs.  W.  W.,  aged  thirty-seven,  in  consultation  with  Dr.  E.  S.  Mann,  of 
Dallastown,  Pa.,  and  had  her  admitted  to  the  Johns  Hopkins  Hospital,  October  6, 
1906.  This  patient  had  never  been  pregnant.  Her  menses  had  commenced  at 
fourteen  and  had  always  been  regular  until  the  previous  year.  Her  last  period 
had  occurred  sixteen  months  before  admission.     About  two  years  before  I  saw  her, 


638 


THE    UMBILICUS    AND    ITS    DISEASES. 


she  had  noticed,  on  moving,  a  sharp,  sticking  pain  in  the  left  lower  abdomen.  For 
about  a  year  and  a  half  she  had  had  some  abdominal  enlargement,  and  eight  weeks 
before  admission  the  abdomen  had  commenced  to  swell  a  great  deal.  The  feet  and 
legs  had  also  been  swollen.     The  patient  gave  a  history  of  having  lost  20  pounds  in 


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Fig.  258. — Giant-cells  in  the  Wall  op  an  Adenocarcinomatous  Cyst  of  the  Urachus.  (X  90  diam.) 
Gyn.-Path.  Nos.  10368  and  10488.  Occupying  the  center  of  the  field  are  slit-like  spaces  lined  on  one  or  both  sides 
with  giant-colls.  The  most  perfect  picture  is  that  seen  at  a.  At  6  is  a  giant-cell  lying  in  the  stroma.  From  this  picture 
as  a  whole  one  gets  the  impression  that  these  slit-like  spaces  may  be  due  to  the  cracking  of  brittle  giant-cells.  At  c 
are  the  epithelial  cells  lining  a  gland-like  space  of  the  carcinomatous  cyst.  Scattered  throughout  the  field  are  quantities 
of  small  round-cells.  Many  of  these  have  absorbed  brown  pigment,  have  swollen  up,  and  at  first  sight  look  like  vacuoles. 
In  the  center  of  these  pale  round  or  oval  spaces  the  small  round,  deeply  staining  nucleus  is  still  clearly  visible.  At  d 
the  stroma  has  undergone  almost  complete  hyaline  transformation. 


the  past  six  months.     She  had  had  dysuria,  and  had  had  to  void  four  or  five  times 
during  the  night. 

On  admission  it  was  noted  that  she  was  a  well-nourished  woman,  weighing  172 
pounds.  The  abdomen  was  markedly  distended.  It  rose  rather  abruptly  from 
the  symphysis  to  the  umbilicus,  and  then  gradually  shaded  off  to  the  xiphoid.     On 


MALIGNANT    CHANGES    IN    THE    URACHUS. 


639 


percussion  fluid  was  evident  in  all  parts  of  the  abdomen.  About  two  months 
before  she  had  noticed  large  and  small  lumps  in  various  parts  of  the  abdomen. 
Some  of  these  were  fully  an  inch  in  diameter,  and  they  had  sharp  edges. 


y\i 


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Fig.  259. — Giant-cells  in  the  Wall  of  an  Adenocarcinoma  of  the  Urachus.  ( X  90  diam.) 
Gyn.-Path.  Nos.  10368  and  104SS.  At  a  is  a  slit-like  space  lined  on  both  sides  with  a  large  giant-cell.  The  nuclei 
of  the  giant-cells  are  irregularly  distributed  and  stain  deeply.  Extending  from  one  end  of  the  space  to  the  other  is  a 
delicate  strand.  This,  under  a  higher  power,  was  found  to  contain  two  small  nuclei.  At  b  is  an  irregular  oblong  space 
with  a  large  giant-cell  in  the  center  of  its  upper  margin,  and  an  irregular  mass  of  protoplasm  containing  numerous  nuclei 
bordering  its  lower  margin;  projecting  into  the  cavity  from  either  end  are  delicate  filaments  of  stroma  devoid  of  nuclei. 
At  c  is  a  series  of  parallel  slits.  The  tissue  at  this  point  consists  of  hyaline  material.  Most  of  these  slits  have  no  lining 
whatsoever,  but  both  the  upper  and  lower  slit  have  small  giant-cells  attached  to  their  margins.  At  d  is  a  slit-like  space 
lined  with  giant-cells,  e  is  a  giant-cell  that  could  be  clearly  focused  at  another  level.  It  was  irregularly  triangular  in 
shape,  and  contained  a  quantity  of  oval,  uniformly  staining  nuclei  arranged  chiefly  at  one  end  of  the  cell.  There  were 
other  giant-cells  scattered  throughout  the  field.  The  protoplasm  of  some  of  these  was  brownish  in  color,  apparently 
owing  to  the  absorption  of  old  blood-pigment.  The  stroma  of  the  cyst-wall  in  this  region  consisted  of  fibrous  tissue. 
In  the  vicinity  of  these  giant-cells  and  in  the  neighborhood  of  the  slit-like  spaces  it  showed  a  great  deal  of  hyaline  trans 
formation;  many  of  the  small  round-cells  that  still  persisted  were  swollen  and  contained  a  yellowish  or  brownish  pig- 
ment— undoubtedly  caused  by  old  hemorrhage. 


On  pelvic  examination  the  cervix  was  found  to  be  perfectly  normal;    nothing- 
further  could  be  made  out. 

Operation  (October  8,  1906). — On  opening  the  abdomen  I  immediately  came 


640 


THE    UMBILICUS   AND    ITS   DISEASES. 


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Fig.  260. 


MALIGNANT    CHANGES    IN   THE    URACHUS.  G41 

in  contact  with  the  contents  of  a  cyst.  This  cyst  was  large,  multilocular,  and 
intimately  adherent  to  the  anterior  and  lateral  abdominal  walls  (Fig.  257).  At 
first  I  thought  it  was  impossible  to  remove  it,  but  on  continuing  the  incision  upward 
we  entered  the  general  peritoneal  cavity.  I  then  delivered  the  tumor  from  above 
downward.  Its  pedicle  sprang  from  the  top  of  the  bladder.  This  pedicle  was  1 
cm.  broad  and  2  mm.  thick.  Raw  areas  were  left,  both  on  the  anterior  and  lateral 
abdominal  walls.  The  bleeding  was  checked  by  sliding  over  the  peritoneum  as  far 
as  possible,  thus  bringing  the  raw  areas  together  and  diminishing  the  size  of  the 
denuded  space. 

Both  ovaries  were  normal  in  size,  but  were  somewhat  glued  down  to  the  pelvic 
floor.  As  the  pedicle  of  the  cyst  sprang  from  the  bladder,  I  thought  it  advisable 
to  turn  it  in,  fearing  that  there  might  be  an  opening  between  the  bladder  and  the 
cyst.  In  the  pelvis  were  metastatic  deposits,  some  of  them  very  minute,  others 
irregular,  somewhat  translucent,  and  fully  1  cm.  in  diameter.  The  appendix  was 
removed,  and  the  abdomen  closed.  The  patient  was  discharged  November  5, 
1906.  In  answer  to  an  inquiry  Dr.  Mann  wrote  me  that  the  patient  died  January 
8,  1908. 

Gyn.-Path.  Nos.  10368  and  10488.—  The  cyst-walls  vary 
considerably  in  thickness.  At  some  points  they  are  thin  and  transparent;  at 
others  they  reach  the  thickness  of  about  2  cm.  These  solid  areas  also  contain  cysts, 
and  in  the  small  cysts  is  a  blackish-colored  fluid.  The  entire  specimen  is  vascular, 
and  in  some  places  friable  and  apparently  malignant. 

On  histologic  examination  the  walls  are  found  to  consist  in  part  of  fibrous  tissue, 
with  a  definite  laminated  arrangement.  In  many  places  necrosis  has  taken  place, 
and  the  tissue  presents  a  homogeneous  appearance  or  takes  the  stain  very  poorly. 
At  other  points  in  the  walls  the  connective-tissue  cells  have  taken  up  much  brown 
pigment,  evidently  from  a  long-standing  hemorrhage.  Here  and  there  throughout 
the  walls  are  slit-like  spaces,  the  smaller  ones  surrounded  by  giant-cells  *  (Fig.  258) . 
The  giant-cells  really  consist  of  large  masses  of  protoplasm  containing  oval  or  round, 
deeply  staining  nuclei  (Fig.  260),  and  some  of  these  nuclei  are  four  or  five  times 
the  size  of  the  surrounding  ones.  Where  the  cavities  are  larger,  giant-cells  may 
be  seen  clinging  to  one  side  of  the  cavity,  other  portions  of  the  cavity  being  devoid 
of  a  lining  (Fig.  259).  At  certain  points  are  aggregations  of  giant-cells,  and  inter- 
spersed are  small,  slit-like  spaces.  One  is  instantly  reminded  of  the  giant-cells 
and  slit-like  spaces  noted  by  Bondi,  and  on  careful  examination  we  found  here  and 

*  I  am  fully  aware  of  the  frequency  with  which  foreign-body  giant-cells  are  prone  to  occur 
in  the  walls  of  certain  cysts  and  elsewhere,  but  the  giant-cells  in  this  case  are  rather  unusual, 
hence  I  have  described  them  more  or  less  in  detail. 


Fig.  260. — Giant-cells  in  the  Wall  of  an  Adenocarcinomatous  Cyst  of  the  Ukachus.  ( X  90  and  300  diam.) 
Gyn.-Path.  Nos.  10368  and  10488.  A.  a  seems  to  be  a  large,  gland-like  space  filled  with  coagulated  blood  and 
exfoliated  epithelium.  It  is  lined  with  one  layer  of  low  cuboid  epithelium,  well  seen  at  b.  c  is  a  large  blood-vessel. 
Scattered  throughout  the  stroma  of  the  cyst-wall  are  giant-cells  and  quite  a  number  of  slit-like  spaces  lined  with  giant- 
cells.     Traversing  the  slit-like  spaces  (d)  are  delicate  strands,  one  of  which  contains  very  small  nuclei. 

B.  This  shows  an  enlargement  of  the  oblong  area  in  A.  The  stroma  consists  of  fibrous  tissue.  At  a  is  a  nest  of 
cancer-cells  which  has  retracted  from  the  surrounding  connective  tissue.  6  is  a  deposit  of  calcareous  material  near 
the  wall  of  a  blood-vessel,  c  and  d  are  slit-like  spaces,  c  is  lined  with  a  ribbon  of  protoplasm  showing  nuclei  scat- 
tered fairly  evenly  throughout  it.  It  is  impossible  to  detect  any  division  of  the  protoplasm  into  individual  cells.  The 
space  d  is  lined  with  a  wide  zone  of  protoplasm  showing  many  nuclei,  uniform  in  size  and  staining  properties,  equally 
distributed  throughout  the  protoplasm,  e  is  another  slit-like  space  lined  with  a  ribbon  of  protoplasm  containing 
only  a  single  row  of  nuclei. 
42 


642 


THE    UMBILICUS    AND    ITS    DISEASES. 


there  crystals  lying  in  the  cavity,  such  as  were  also  found  by  Bondi.  Other  portions 
of  the  tumor  show  gland-like  spaces  lined  with  one  or  more  layers  of  epithelium 
(Fig.  261).  The  nuclei  of  the  epithelial  cells  are  oval  and  vesicular,  or  are  deeply 
staining,  and  the  epithelium  itself  is  of  the  low  cylindric  variety.  In  some  places 
the  epithelium  has  proliferated  to  a  moderate  extent.     The  gland  arrangement  in 


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Fig.  261. — Adenocarcinoma  op  the  Urachus.  (  X  90diam.) 
Gyn.-Path.  Nos.  10368  and  10488.  The  growth  at  this  point  bears  considerable  resemblance  to  a  papillocystoma 
of  the  ovary;  it  consists  of  large  and  small  irregular  spaces  lined  almost  exclusively  with  one  layer  of  cuboid  or  low  cyl- 
indric epithelium,  a  is  a  very  good  example  of  one  of  the  spaces  with  a  projection  into  it  from  the  side.  This  space  is 
lined  with  one  layer  of  cuboid  epithelium  containing  relatively  round  and  deeply  staining  nuclei.  These  nuclei  are 
particularly  well  seen  at  6.  The  granular  contents  in  the  gland-spaces  consist  of  coagulated  epithelial  secretion.  The 
epithelial  elements  in  the  left  lower  part  of  the  picture  have  to  a  large  extent  melted  away.  The  fibrous  stroma  of  the 
growth  contains  very  few  nuclei,  c  is  one  of  the  blood-vessels  in  the  stroma.  From  this  picture  alone  one  could  not 
tell  definitely  whether  the  growth  was  malignant  or  not.  That  it  is  malignant,  however,  is  definitely  settled  by  a  ref- 
erence to  Kig.  I'll:',,  and  also  by  the  fact  that  at  operation  metastases  were  found. 


some  places  suggests  a  papillary  formation  (Fig.  262),  and  the  gland  cavities  are 
filled  with  a  homogeneous  material  that  takes  the  eosin  stain.  The  epithelial  cells 
at  other  points  are  almost  flat.  There  does  not  seem  to  be  much  variation  in  the 
size  of  the  cells,  and  such  a  picture  alone  would  suggest  a  papillocystoma.  At 
other  points  the  epithelium  has  proliferated  markedly,  so  that  we  have  what 


MALIGNANT   CHANGES    IN    THE    URACHUS. 


643 


appears  to  be  solid  nests;  or  the  epithelium  has  melted   away,  as  is  noted  in 
colloid  carcinoma. 

There  is  no  doubt  we  are  dealing  with  a  multilocular  cyst  that  has  become 
malignant.  This  cyst  certainly  belongs  to  a  rare  type.  Of  the  malignancy,  there 
can  be  no  doubt,  because  metastases  in  the  pelvic  peritoneum  were  noted  at  opera- 
tion (Fig.  263).     It  did  not  spring  from  the  ovaries,  as  they  were  perfectly  normal  in 


Fig.  262. — A  Papillary- like  Area  in  an  Adexocarcixomatous  Cyst  of  the  Urachus.  (X  90  diam.) 
Gyn.-Path.  Nos.  10368  and  10488.  The  picture  is  a  rather  confused  one.  At  a  the  complex  papillary  mass  is 
seen  covered  with  one  layer  of  cuboid  epithelium  having  round,  uniformly  staining  nuclei.  At  b  are  two  definite  gland- 
like spaces.  At  c  is  a  bluntish  projection  of  the  stroma  into  a  gland-space,  d  indicates  the  stroma,  consisting  of  spindle- 
shaped  connective-tissue  cells.  The  gland-spaces  are  filled  with  a  granular,  homogeneous  material  seen  at  e.  (For  the 
appearances  of  the  metastases  see  Fig.  263.) 

size  and  distant  from  the  growth.  Its  pedicle,  as  noted  from  the  history,  sprang 
from  the  top  of  the  bladder.  It  will  further  be  noted  that  during  the  removal  of 
the  tumor  a  large  part  of  the  peritoneum  of  the  anterior  and  lateral  abdominal  walls 
had  to  be  sacrificed.     This  tumor  evidently  originated  from  the  urachus. 

The  mode  of  origin  of  the  giant-cells  has  been  of  especial  interest  to  me.     It  will 
be  noted  that  these  giant-cells  have  been  found  almost  entirelv  in  the  outer  con- 


644 


THE    UMBILICUS   AND    ITS    DISEASES. 


nective-tissue  wall  of  the  large  cyst,  and  that  the  cavities  that  they  line  are  slit- 
like. This  is  particularly  well  seen  in  Fig.  258.  Furthermore,  in  the  vicinity  of 
these  slit-like  spaces  are  well-formed  giant-cells  lying  completely  surrounded  by 
stroma  (Fig.  258,  b).  On  examining  the  space  b  in  Fig.  259,  one  gathers  the 
impression  that  the  tissue  has  been  especially  brittle,  and  that  during  the  process 
of  hardening  the  giant-cells  may  have  split  lengthwise;  this  impression  is  still 
further  strengthened  by  examining  the  area  c  in  Fig.  259.  Here  the  protoplasm 
has  apparently  been  split  up  into  several  long  strands.     At  the  upper  end  of  this 


Fig.  263. — Metastasis  from  Adenocarcinoma  of  the  Urachus.  (  X  90  diam.) 
Gyn.-Path.  Nos.  10368  and  10488.  o  and  a  are  blood-vessels.  Scattered  throughout  the  field  are  nests  of  epithelial 
cells.  Although  originally  the  growth  was  glandular,  the  metastases  have  tended  to  form  solid  nests.  At  6,  however, 
two  gland-like  spaces  can  be  faintly  made  out.  During  the  process  of  hardening  the  cancerous  tissue  tended  to  retract 
from  the  stroma.  This  is  especially  well  seen  at  c.  The  stroma  of  the  growth  showed  considerable  small-round-cell 
infiltration. 


area  there  is  an  intact  giant-cell.  The  finer  structure  of  the  giant-cell  is  well  seen 
in  Fig.  260,  B,  d. 

In  an  examination  of  a  large  number  of  ovarian  cysts  I  have  never  seen  a  picture 
analogous  to  the  one  here  depicted.  To  be  sure,  in  very  young  dermoid  cysts  of 
the  ovary,  giant-cells  are  the  rule,  but  here  they  are  invariably  lining  or  clinging 
to  the  walls  of  small  cysts — such  giant-cells  are  the  embryonic  stages  of  squamous 
epithelium. 

Dr.  William  H.  Welch  informed  me  that  he  had  occasionally  seen  giant-cells 


MALIGNANT    CHANGES    IN    THE    URACHUS. 


645 


similar  to  these  in  the  walls  of  cysts  and  elsewhere,  and  suggested  that  they  might 
be  foreign-body  giant-cells.  He  further  suggested  the  possibility  of  their  develop- 
ing around  crystals.  On  careful  examination  of  many  giant-cells  I  found  just  one 
crystal.  This  was  irregular  in  form.  Whether  the  giant-cells  in  this  case  are  for- 
eign-body cells  or  not  I  cannot  say.  This  point,  of  course,  is  of  interest  only  to  the 
pathologist. 

Bondi  reported  a  small  umbilical  cyst  of  unknown  origin.     He  found  quantities 
of  giant-cells  analogous  to  those  here  depicted  (Fig.  266),  and  in  his  case  some  of 
the  giant-cells  surrounded  crystals.     Although  his 
cyst  was  not  malignant,  it  is  of  such  interest  in 
connection  with  my  case  that  I  shall  here  report 
it  somewhat  in  detail. 


A  RARE  UMBILICAL  CYST. 
Bondi*  reports  this  case  from  Schauta's  clinic. 
The  patient  was  a  woman,  sixty-two  years  of  age. 
She  had  had  three  normal  labors.  About  twenty 
months  before  coming  under  observation  she 
noticed  that  the  umbilicus  was  larger  than  usual, 


** 


pi. 


:>F 


Fig.  264. — An  Umbilical  Cyst.  (After  Bondi.) 
The  original  tumor  was  5  cm.  in  diameter.  The  drawing  has  been 
made  from  the  hardened  specimen,  which  was  much  contracted.  Nearly 
two  years  before  operation  the  patient  had  noted  an  enlargement  at  the 
umbilicus.  The  overlying  skin  was  brownish  in  color,  tense,  and  elastic. 
It  was  slightly  compressible.  H  is  the  skin  covering  the  cyst;  Nr,  the 
confines  of  the  umbilical  depression;  P,  a  prolongation  of  the  peritoneal 
cavity  into  the  mass.  The  walls  of  the  cyst  were  composed  of  two  layers 
— an  outer,  consisting  of  whitish  tissue,  and  an  inner,  homogeneous  zone, 
grayish  brown  in  color.  The  cyst  contents  were  spongy,  yellowish  brown, 
and  soft.     (For  the  histologic  picture  see  Figs.  265  and  266.) 


Fig.  26.5. — Wall  of  an  Umbilical  Cyst. 
(After  Bondi.) 
This  is  a  section  of  the  cyst-wall  seen 
in  Fig.  264.  H  represents  the  skin,  with 
connective  tissue  immediately  beneath  it ; 
B,  a  dense  layer  of  connective  tissue.  Rx, 
granulation  tissue.  In  this  are  areas  con- 
taining small  spaces.  These  spaces,  as  seen 
in  Fig.  266,  are  lined  with  giant-cells.  The 
cells  in  this  layer  contain  blood-pigment. 
The  inner  surface  (F)  consists  of  coarse 
and  fine  threads  of  fibrin. 


and  that  the  abdomen  had  increased  in  size.     She  had  never  noticed  a  tumor  pro- 
jecting outward  beyond  the  level  of  the  umbilicus. 

At  operation,  at  the  umbilicus  was  a  tumor  5  cm.  in  diameter,  the  skin  over  it 
being  brownish  in  color.  It  was  tense  and  elastic,  showed  no  marked  fluctuation, 
and  was  slightly  compressible.  The  abdominal  enlargement  was  due  to  a  multi- 
locular  ovarian  cyst  the  size  of  a  man's  head,  with  torsion  of  the  pedicle  to  the  extent 
of  180  degrees;  the  wall  of  the  cyst  was  partially  necrotic. 

*  Bondi,  J.:  Zur  Kasuistik  der  Nabelcysten.    Monatsschr.  f.  Geb.  u.  Gyn.,  190.5,  xxi,  729. 


646  THE    UMBILICUS    AND    ITS   DISEASES. 

In  the  hardened  specimen  the  umbilical  cyst  was  2.5  cm.  in  diameter.  It 
lav   over  an  outward  prolongation  of  the  abdominal  cavity,   much   as   a  cap 

would  fit  (Fig.  264).     The  walls  of  the 

.v^^T^^-  cys^  nac*  two  layers,  the  outer  consist- 

■>.'!'''  "'''•'      <.  jng   0f  whitish  tissue  2  mm.  thick.     It 

V,  '   /Sl'Vi*  y&SZ?'  "I  "".s*' "'  was  adherent  to  the    skin  and  to  the 
*."  'Mi'1^,^  ''    *is*»  peritoneum,  and  the  inner  zone  consisted 
\     ii^v-''F~'~'    u; $?l£'Z  •^N;*  of    a   broad,    homogeneous,    gray-brown 
H%» .                           -,  -:  ^  tissue.     The  cyst  contents  were  spongy, 
%    %\Sj!/<?^j.-M?^,; l||-:  yellowish  brown,   and  soft.      Its  length 
}»  ;f                   '  "^/v^C       — *^^  in  the  hardened  specimen  was  2.5  cm., 
^   l*^/j§^-              '^"    "<#^:f  and  its  greatest  thickness,  1.5  cm.     The 
v\'%fj|&/^/;  )'    ^,;f.-."--^'*  *£•     V  outer  wall  of  the  cyst  consisted  of  fibrous 
,Ui^  ^-^^^'v^^  tissue,  which  gradually  passed  over  into 
s^- •*'-'*   v*|^'  the  inner,  homogeneous  lining,   consist- 
'*  V  *'^    ;*    'o» '"■*  ing  of  young  fibrous  tissue.     This  gradu- 
"*%t£     j  ,  v-**  ally  merged  into  the  granulation  tissue 
*"  **-    bx  which  lined  the  cavity.     The  granulation 
fig.  266.— Giaxt-cells  in  the  Wall  of  an  u.mbili-  tissue  here  and  there  contained  blood-pig- 
on  i.)  ment.      Here  and  there  near  the  inner 

Scattered  throughout  the  inner  wall  of  the  cyst 

(Fig.  26.5)  were  aggregations  of  small,  siit-iike  spaces.        surf  ace  were  numerous  spaces,  often  oc- 

Some  of  these  are  lined  with  one  layer  of  epithelium,  CUlTmg  ill   groups.       These  Were  regularly 

others  with  giant-cells.     The  nuclei  of  the  giant-cells  ....  ,-,-,.  __  _  .   o^^x 

are  uniform  and  fairly  evenly  distributed  throughout  lmed  With  giailt-CellS  (t  lgS.    265  and  266)  . 

the  protoplasm.  jn  tnese  spaces  were  crystals  showing  that 

the  spaces  were  not  artefacts.  Bondi 
says  that  it  was  not  a  dermoid,  but  a  peritoneal  cyst,  into  which  a  hemorrhage  had 
occurred. 

It  is  possible  that  these  giant-cells  were  foreign-body  giant-cells.  As  already 
pointed  out,  they  bear  a  marked  resemblance  to  those  noted  in  the  malignant  cyst 
of  the  urachus  I  have  just  recorded  so  fully.     (See  Figs.  258,  259,  and  260.) 


LITERATURE  CONSULTED  ON  MALIGNANT  GROWTHS  OF  THE  URACHUS  AND  URA- 
CHAL REGION. 

Aveling:  Brit.  Gyn.  Jour.,  1886-87,  ii,  56,  187. 

Bondi,  J.:  Zur  Kasuistik  der  Nabelcysten.     Monatsschr.  f.  Geb.  u.  Gyn.,  1905,  xxi,  729. 

Doran,  A.:  Stanley's  Case  of  Patent  Urachus  with  Observations  on  Urachal  Cysts.  St.  Bar- 
tholomew's Hospital  Reports,  1898,  xxxiv,  33. 

Doran,  A.  H.  G.:  Urachal  Cyst  Simulating  Appendicular  Abscess;  Arrested  Development  of 
Genital  Tract;  with  Notes  on  Recently  Reported  Cases  of  Urachal  Cysts.  The  Lancet, 
1909,  i,  1304. 

Fischer,  H.:  Die  Eiterungen  im  subumbilicalen  Raume.  Volkmann's  Sammlung  klin.  Vor- 
trage,  N.  F.,  No.  89  (Chir.  No.  24),  Leipzig,  1894,  519. 

Frank,  T.:   Zur  Casuistik  der  Urachustumoren.     Inaug.  Diss.,  Wurzburg,  1893. 

Graf,  F.:  Urachusfisteln  und  ihre  Behandlung.     Inaug.  Diss.,  Berlin,  1896. 

Hoffmann,  C.  E.  E.:  Zur  pathologisch-anatomischen  Veranderung  des  Harnstrangs.  Arch. 
der  Heilkunde,  1870,  xi,  373. 

Koslowski,  B.  S. :  Ein  Fall  von  wahrem  Nabeladenom.     Deutsche  Zeitschr.  f.  Chir.,  1903,  lxix,  469. 

Rotter:  Blasencarcinom  kombinirt  mit  Urachuscyste.     Centralbl.  f.  Chir.,  1897,  xxiv,  604. 

Wolff,  C.  C. :  Beitrag  zur  Lehre  von  den  Urachuscysten.     Inaug.  Diss.,  Marburg,  1873. 


CHAPTER  XXXVIII. 
BLEEDING  FROM  THE  URACHUS  INTO  THE  BLADDER. 

The  literature  on  this  subject  is  a  negligible  quantity.  W.  Ramsay  Smith  * 
reports  a  case  which,  although  somewhat  obscure,  may  be  mentioned  here. 

The  patient,  a  female  infant,  was  born  August  3d.  The  labor  was  short,  and 
the  child  brought  away  with  forceps.  The  cord  appeared  to  be  normal.  On  the 
second  night,  August  5th,  a  large  quantity  of  bright-red  blood  was  noticed  on  the 
infant's  binder.  It  appeared  on  that  night  only,  and  the  nurse  noticed  that  it  was 
coming  not  from  the  cord,-  but  from  the  umbilicus  at  the  side  of  the  cord.  Two 
days  later  (August  7th)  the  child  had  an  attack  of  diarrhea,  and  there  was  a  good 
deal  of  blood  in  the  stools,  and  it  was  noticed  that  this  blood  was  coming  from  the 
urethra.  On  August  8th  the  bleeding  was  very  severe,  there  being  over  two  tea- 
spoonfuls  at  a  time.  The  blood  always  appeared  when  the  bowels  moved,  but  it 
came  from  the  urethra.  The  diarrhea  ceased,  and  the  bleeding  stopped  on  August 
9th.  Smith  thought  that  the  bleeding  took  place  from  the  hypogastrics,  and 
escaped  to  the  bladder  along  the  urachus.  Ballantyne  felt  somewhat  reluctant 
to  accept  this  explanation,  but  said  that,  under  the  circumstances,  it  was  difficult 
to  suggest  any  that  was  more  satisfactory. 

A  few  years  ago,  while  discussing  diseases  of  the  umbilical  region  with  Dr. 
Edward  Reynolds,  of  Boston,  he  mentioned  the  fact  that  on  several  occasions  he 
had  noted  bleeding  from  the  urachus  into  the  bladder.  Later  I  wrote  asking  him 
kindly  to  furnish  me  with  the  data  he  had  bearing  on  the  subject.  His  reply  was  as 
follows : 

"With  regard  to  my  recent  hematuric  case,  the  patient  was  a  physician  about 
thirty-five  years  old,  from  whom  I  removed  the  appendix  about  two  years  ago. 
She  came  to  me  on  the  seventh  of  February,  saying  that,  after  very  hard  and  long 
automobiling  over  rough  country  roads  a  few  days  before,  she  had  been  seized  by 
a  sudden  urgent  desire  to  urinate,  and  had  passed  a  quantity  of  bloody  urine. 
Since  then  urination  had  been  normal,  but  the  urine  was  slightly  blood-stained. 
She  informed  me  that  she  had  noticed  that  the  first  part  of  the  urine  was  clear  and 
that  the  blood  came  with  the  last  few  drops.  When  I  first  looked  into  her  bladder 
the  small  amount  of  urine  was  clear  (she  had  just  emptied  it).  I  inspected  the 
trigonum  and  fundus  of  a  normal  bladder  carefully  in  the  knee-chest  position,  and, 
on  turning  the  point  of  the  cystoscope  forward,  found  that  in  the  interval  the  urine 
had  become  distinctly  pink.  I  then  emptied  the  bladder  thoroughly  with  the 
evacuator,  and  saw  a  small  stream  of  blood  flowing  from  the  orifice  of  the  urachus. 
The  patient  has  written  me  since  that  the  hematuria  stopped  within  forty-eight 
hours  after  her  visit  to  me,  and  that  there  was  no  recurrence.  I  told  her  that  I 
thought  there  was  no  other  treatment  than  the  removal  of  the  urachus;  that  I 
should  not  advise  that  unless  the  symptoms  were  persistent;   that  I  should  advise 

*  Smith,  W.  Ramsay:  Obstet.  Trans.,  Edinburgh,  1892-93,  xviii,  53. 

647 


648  THE    UMBILICUS   AND    ITS    DISEASES. 

it  if  the  hematuria  were  recurrent.  I  asked  her  to  keep  me  informed  of  her  prog- 
ress, and  I  think  that  she  will  do  so. 

''This  is  not  my  first  case  of  the  kind.  A  good  many  years  ago,  when  I  was 
doing  a  large  out-patient  clinic  and  making  a  great  many  cystoscopic  examinations, 
I  saw  a  number  of  cases,  I  should  guess  from  half  a  dozen  to  a  dozen,  in  which  minor 
vesical  symptoms  seemed  to  be  associated  with  a  reddened,  eroded  condition  of  the 
vesical  mucous  membrane  immediately  about  a  small  orifice  in  the  upper  and  ante- 
rior part  of  the  bladder,  which,  after  some  study,  I  grew  to  consider  as  the  orifice 
of  a  patent  urachus,  and  which,  on  close  inspection,  I  could  recognize  in  a  consider- 
able proportion  of  bladders  in  which  it  was  not  making  trouble.  I  believe  that  this 
slight  anomaly  is  very  common,  and  that  it  is  a  not  unimportant  lurking-place  for 
bacteria  in  infected  bladders.  In  at  least  two  cases  in  these  old  days  I  saw  bleeding 
from  this  orifice;  I  think  in  more  than  that  number,  but  the  conditions  of  the 
clinic  made  careful  record  keeping  very  difficult.  I  should  say  that  the  hematuria 
was  transient  but  recurrent.  I  do  not  know  the  ultimate  outcome.  The  patients 
in  that  clinic  were  all  of  a  class  which  it  is  difficult  to  follow  up  afterward." 

Dr.  Reynolds'  observation  clearly  demonstrates  that  in  some  cases  blood  does 
escape  from  the  persistent  urachus  into  the  bladder.  His  suggestion  that  the 
urachal  opening  is  probably  the  lurking-place  of  bladder  infections  is  fully  borne 
out  by  the  cystitis  frequently  noted  where  a  partially  patent  urachus  exists. 


CHAPTER  XXXIX. 
TUBERCULOSIS  OF  THE  PATENT  URACHUS. 

I  have  been  able  to  find  only  two  cases  of  this  character  in  the  literature.  The 
first  case  was  recorded  by  Briddon  and  Eliot,  the  second  by  Eastman. 

Dr.  Thacher,  who  made  the  pathologic  report  on  the  extirpated  urachus  in 
Briddon  and  Eliot's  case,  after  giving  a  very  careful  and  guarded  description, 
decided  that  the  condition  was  probably  tuberculous.  Dr.  Eastman  sent  us  his 
specimen  and  we  have  been  able  to  demonstrate  tubercle  bacilli  in  the  urachus. 

"Tubercular  Degeneration  of  the  Patent  Urachus 
in  the  Adult.* — R.  M.,  aged  nineteen,  Roumanian;  married.  Admitted  July 
17,  1899.  No  tubercular  family  or  personal  history.  The  patient  has  always  been 
well  until  five  weeks  ago,  when  she  began  to  have  slight  pain,  with  heat,  redness', 
and  swelling  in  the  region  of  the  umbilicus,  the  navel  having  previously  been  always 
normal  in  appearance.  The  symptoms  increased  for  two  weeks,  at  the  end  of 
which  time  there  was  a  small  red  tumor,  the  size  of  a  pea,  in  the  region  of  the 
umbilicus.  During  this  time  the  patient  suffered  intensely  from  severe,  sharp 
pain,  almost  constantly  present,  in  the  hypogastric  region,  with  well-marked 
vesical  tenesmus,  increased  frequency  of  micturition  (often  voiding  urine  every 
hour),  and  occasionally  a  small  amount  of  blood  in  the  urine.  At  the  end  of  the 
two  weeks  the  swelling  opened  spontaneously,  discharging  some  cloudy  fluid  with 
a  uriniferous  and  foul  odor,  the  pain  and  swelling  soon  subsiding.  About  four 
days  after  the  discharge  of  fluid  at  the  umbilicus,  she  ceased  to  pass  water  normally, 
and  since  then  she  has  had  a  constant  discharge  of  cloudy  fluid  of  a  uriniferous 
odor,  at  times  slightly  blood-stained,  through  the  opening  at  the  umbilicus.  She 
has  lost  considerable  flesh  and  strength  during  the  period  of  five  weeks. 

"Physical  Examination. — The  patient  is  markedly  anemic  and  is  apathetic. 
The  facies  is  flushed;  the  tongue  is  moist  and  not  heavily  coated.  The  superficial 
glands  are  not  enlarged.  In  the  heart  there  is  a  hemic  murmur  over  the  pulmonic 
area,  systolic  in  time.  Percussion  of  the  lungs  is  normal,  but  the  breathing  is 
rather  poor.  The  abdomen  is  soft,  retracted,  and  no  masses  can  be  felt.  At  the 
inferior  portion  of  the  umbilicus  is  a  small  sinus  with  everted  and  ulcerated  edges, 
which  discharges  a  seropurulent  fluid  of  uriniferous  odor.  A  probe  introduced  into 
the  sinus  goes  downward  and  extends  evidently  as  far  as  the  bladder.  The  bladder 
does  not  percuss  high,  but  there  is  some  tenderness  on  pressure  over  the  suprapubic 
region.  Urine  analysis  at  the  time  of  admission  showed  very  turbid  and  cloudy 
urine,  with  specific  gravity  of  1014,  15  per  cent  of  sediment,  reaction  strongly 
alkaline,  and  odor  foul  and  ammoniacal.  There  was  10  per  cent  of  albumin,  no 
blood,  a  large  amount  of  mucus,  much  pus,  and  many  vesical  cells,  with  many 
crystals  of  triple  phosphate.  No  casts  were  found.  She  was  placed  upon  bladder 
irrigations  twice  daily,  with  warm  0.5  per  cent,  boric-acid  solution,  and  salol  (gr.  v) 

*  Briddon,  C.  K.,  and  Eliot,  E.:  Med.  and  Surg.  Reports,  Presbyterian  Hospital,  New  York, 
January,  1900,  iv,  30. 

649 


650  THE   UMBILICUS   AND    ITS   DISEASES. 

three  times  a  day.  There  was  no  improvement  under  this  treatment,  either  in  the 
character  of  the  urine  or  in  the  patient's  general  condition,  except  that  she  had 
slightly  less  pain.  At  the  end  of  a  week  the  bladder  irrigation  was  changed  to 
carbolic  acid,  in  strength  of  1 :  120.  This  also  seemed  to  have  no  effect  upon  the 
urine,  frequent  examinations  up  to  the  time  of  operation  giving  about  the  same 
result.  As  at  the  first  analysis,  the  specific  gravity  never  rose  above  1014;  the 
urine  always  remained  alkaline  and  was  full  of  pus  and  mucus.  The  temperature 
course  was  irregular,  varying  between  99.5°  F.  and  102°  F.,  and  did  not  seem  to  be 
influenced  in  any  way  by  the  bladder  washing.  During  a  period  of  several  days  of 
fairly  constant  low  temperature  the  patient  gave  a  moderately  characteristic 
tuberculin  reaction.  The  average  daily  amount  of  urine  voided  by  the  urachus 
varied  from  15  to  20  ounces.  At  intervals  of  several  days  she  voided  a  few  drams 
or  an  ounce  of  urine  per  urethram. 

"  Owing  to  the  obstinate,  unyielding  cystitis,  it  was  thought  advisable  to  do 
a  suprapubic  cystotomy  for  purposes  of  drainage. 

" Operation  (August  25th) . — Dr.  Eliot.  Nitrous  oxid  and  ether;  asepsis;  dor- 
sal position.  A  catheter  was  introduced  through  the  urethra  into  the  bladder  and 
urine  was  withdrawn.  Four  ounces  of  warm  1  per  cent  boric-acid  solution  were 
then  gently  thrown  into  the  bladder  by  a  fountain  syringe,  six  ounces  of  water, 
injected  into  a  Barnes  dilator,  having  been  previously  inserted  into  the  rectum. 
A  23^-inch  median  incision  was  then  made  above  the  pubis  and  deepened  down  to 
the  space  of  Retzius.  The  soft  cellular  tissue  here  being  pushed  aside  and  the 
bladder  presenting,  two  silk  sutures  were  passed  in  a  longitudinal  fashion  through 
its  wall,  separated  by  a  distance  of  one  inch,  these  sutures  being  placed  for  purposes 
of  traction.  The  bladder  was  then  opened  between  the  silk  sutures,  the  boric- 
acid  fluid  pouring  out  into  the  wound.  The  incision  in  the  bladder-wall  being 
subsequently  enlarged  upward,  disclosed  the  urachus  opening  into  the  fundus  of 
the  bladder.  There  were  several  small  areas  of  ulceration  on  the  posterior  wall  of 
the  bladder,  and  parts  of  the  ulcers,  together  with  a  portion  of  the  urachus,  were 
secured  for  microscopic  examination.  The  ulcerated  areas  upon  the  bladder-wall 
were  cauterized  with  a  thermocautery.  The  lumen  of  the  urachus  was  packed 
with  a  strip  of  iodoform  gauze,  the  cavity  of  the  bladder  being  drained  through  the 
suprapubic  wound  in  the  usual  way  by  means  of  a  tube. 

"Report  by  J.  S.  Thacher,  Pathologist.- — A.  Minute  fragment  of  tissue  from 
urachus.  Microscopic  examination  shows  a  mass  of  smooth  muscle  and  connec- 
tive tissue.  The  muscle-cells  vary  somewhat  in  size  and  shape,  and  are  irregular 
in  arrangement. 

"B.  Minute  fragments  from  base  of  bladder.  The  epithelium  is  partly  de- 
stroyed, and  the  tissues  are  much  inflamed.  The  inflammation  appears  to  be  of 
some  standing. 

"The  bladder  was  drained  very  satisfactorily  for  ten  days  by  the  siphon  drain- 
age apparatus,  the  suprapubic  wound  remaining  comparatively  clean  and  dry.  The 
patient's  temperature  was  increased  for  six  days  following  the  operation.  Recovery 
was  uneventful.  Bladder  irrigation  with  carbolic  acid,  1:40,  was  employed,  when 
the  drainage  apparatus  was  dispensed  with,  the  urine  clearing  up  slightly  and  the 
pain  becoming  much  less  severe.  She  seemed  to  improve  in  general  health  to  a 
moderate  degree.  Urine  was  not  voided  normally  after  the  suprapubic  operation 
had  been  performed. 


TUBERCULOSIS    OF    THE    PATENT    URACHUS.  651 

"September  25th:  Urine,  for  about  one  week,  has  had  much  less  pus  and  mu- 
cus in  it,  and  hypogastric  pain  has  been  much  less  severe.  It  was  then  decided 
to  attempt  an  extirpation  of  the  patent  urachus,  leaving  the  suprapubic  wound 
unmolested. 

"Operation  (September  27th). — Dr.  Briddon;  nitrous  oxid  and  ether;  asepsis; 
dorsal  position.  A  median  incision  was  made  from  the  umbilicus  down  to  the 
suprapubic  wound  of  the  previous  operation,  exposing  the  linea  alba,  which  was 
split  up  in  the  line  of  the  incision,  exposing  granulation  tissue  forming  the  wall 
of  the  patent  urachus.  By  blunt  dissection  this  tissue  was  then  dissected  free 
from  the  underlying  thickened  peritoneum,  during  which  process  the  urachus  was 
opened  longitudinally  through  a  portion  of  its  extent.  The  walls  of  the  urachus 
were  nearly  a  quarter  of  an  inch  thick,  and  their  diameter  was  about  half  an  inch. 
At  its  point  of  junction  with  the  bladder  it  was  cut  transversely  and  removed,  the 
general  cavity  of  the  peritoneum  not  being  opened.  A  clean  surface  was  thus  left, 
whose  floor  was  formed  by  the  thickened  peritoneum,  and  its  sides  by  the  divided 
portion  of  the  linea  alba.  This  tract  was  closed  by  eight  interrupted  chromic 
catgut  sutures,  passing  from  one  side  to  the  other  through  the  skin  and  linea 
alba,  thus  approximating  the  raw  edges  of  the  tract.  A  sterile  dressing  was 
placed  on  the  sutured  wound,  a  rubber  drainage-tube  and  iodoform  gauze  being 
left  in  the  suprapubic  wound. 

"  Report  of  J.  S.  Thacher,  Pathologist. — Extirpation  of  patent  urachus.  Mi- 
croscopic examination :  Granulation  tissue ;  spots  of  marked  infiltration  by  leuko- 
cytes; several  small  necrotic  spots;  many  giant-cells;  some  tissue  resembling 
tubercle  tissue — probably  tubercular. 

"  Recovery  from  the  operation  was  uneventful.  The  bladder  was  drained  satis- 
factorily for  ten  days,  the  wound  for  urachus  extirpation  healing  by  primary  union 
without  complication.  Her  general  health  rapidly  improved,  and  she  had  gradually 
less  hypogastric  pain  and  discomfort.  For  a  few  weeks  the  patient  voided  no  urine 
normally,  all  being  discharged  through  the  suprapubic  wound.  Since  then  she 
has  passed  almost  every  day  one  or  more  ounces  of  urine  per  urethram,  in  gradually 
increasing  quantity.  Her  general  condition  is  very  much  improved,  the  suprapubic 
wound  is  steadily  closing,  and  urinary  analysis  now  gives  but  3  per  cent,  of  albumin, 
with  much  less  pus  and  mucus. 

"Repeated  examination  of  urine  failed  to  discover  any  tubercle  bacilli,  and 
careful  physical  examination  by  G.  A.  Tuttle  failed  to  detect  any  evidence  of 
pulmonary  or  other  visceral  tuberculosis. 

"Examination  conducted  by  Dr.  Tuttle,  in  the  pathologic  laboratory,  of  the 
small  ulcers  which  were  excised  from  the  wall  of  the  bladder  at  the  time  of  the  first 
operation,  failed  to  yield  positive  indications  of  tuberculosis;  conclusive  evidence 
at  last  was  furnished  by  the  examination  by  Dr.  Thacher  of  the  urachus  itself, 
removed  by  Dr.  Briddon  at  the  time  of  the  second  operation.  Inferences  are 
always  uncertain,  and  although  the  statement  that  the  tubercular  process  originated 
in  the  patent  remnant  of  the  duct  itself  is  not  entirely  justifiable,  nevertheless,  the 
fact  remains  that  examination  of  its  wall  after  removal  showed  much  more  abundant 
evidence  of  tuberculosis  than  did  the  portion  of  the  bladder-wall  removed  earlier 
by  suprapubic  cystotomy." 

In  the  case  under  discussion  the  removal  of  the  urachus  was  accomplished  with- 
out opening  the  general  peritoneal  cavity. 


652 


THE    UMBILICUS    AND    ITS    DISEASES. 


I  was  particularly  anxious  to  see  a  section  from  this  case,  and  accordingly  wrote 
Dr.  Thacher.  In  his  reply,  dated  New  York,  April  8,  1914,  he  gave  me  the  results 
of  his  examination,  but  said  the  original  slide  could  not  be  located. 

Tuberculosis  of  the  Urachus.*  ■ — Dr.  Eastman  has  just  recorded 
a  very  interesting  case  of  tuberculosis  of  the  urachus  in  a  girl  aged  nineteen. 

"Family  History. — Father  died  of  cancer  of  the  stomach  at  the  age  of  fifty-one; 
one  brother  died  during  infancy  of  meningitis;  history  otherwise  negative,  par- 
ticularly as  relates  to  tuberculosis  or  neoplasms. 


Fig.  267. — Tuberculosis  of  the  Urachus. 

This  is  a  low-power  photomicrograph  from  Dr.  J.  R.  Eastman's  case.  At  a  is  an  area  of  caseation  surrounded  by 
tissue  closely  resembling  that  found  in  tuberculosis.  The  outer  walls  are  composed  of  non-striped  muscle  and  fibrous 
tissue.  Scattered  throughout  this  tissue  are  localized  foci  more  or  less  characteristic  of  those  noted  in  tuberculosis. 
The  areas  b  and  c  are  very  suggestive  of  tubercles. 

The  high-power  picture  of  the  area  b  is  shown  in  Fig.  268;   that  of  the  area  c,  in  Fig.  269. 


"Personal  History. — Typhoid  at  seventeen  with  good  recovery;  history  other- 
wise negative;  patient  married  two  years  and  four  months;  one  pregnancy,  child 
living  and  well;  at  no  time  night-sweats  or  protracted  cough;  no  characteristic 
temperature  history;   no  other  evidences  of  tuberculosis. 

"Menstrual  History. — Menstruation  began  at  twelve;  regular;  duration  five 
days  and  free;  no  change  in  type  since  marriage  or  labor. 

"Urination. — No  increase  in  frequency,  no  nocturnal  urination.  Three  diurnal 
urinations;   never  any  blood  or  burning  or  stinging. 

"History  of  illness  for  which  patient  entered  hospital. — This  trouble  began  ten 

*  Eastman,  Joseph  Rilus:   Amer.  Jour,  of  Obstetrics,  1915,  lxxii,  640. 


TUBERCULOSIS    OF    THE    PATENT    URACHUS. 


653 


months  before  entrance.  While  working  in  the  garden,  pain  was  felt  at  a  point  in 
the  mid-line  of  the  abdomen  between  the  symphysis  pubis  and  the  umbilicus.  At 
this  time  patient  noticed  a  lump  at  the  point  designated,  the  size  of  a  small  apple. 
There  was  not  much  actual  pain  nor  soreness.  The  mass  did  not  increase  in  size 
but  the  tenderness  remained.  This  condition  persisted  for  three  months  when  a 
pin-point  opening  appeared  in  the  mid-line  of  the  anterior  abdominal  wall,  half-way 
between  the  symphysis  pubis  and  the  umbilicus.  This  opening  discharged  a  clear 
watery  fluid  for  about  a  week.  Then  a  serous  crust  closed  the  opening.  The 
opening  again  discharged  after  about  a  week,  continuing  to  do  so  for  one  week  and 
again  the  crust  was  formed.  This  process  of  closing  and  opening  continued  for 
several  months.  The  size  of  the  tumor  did  not  change.  The  tenderness  still  per- 
sisted.    There  had  never  been  any  disturbance  of  the  bladder,  intestines  or  uterus. 


a 

•1 


b 


x 


d  c 

Fig.  26S. — An  Area  Suggesting  a  Tubercle. 
This  picture  is  a  high-power  magnification  of  the  area  b  in  Fig.  267.     Its  confines  are  indicated  by  x  and  x.     Scat- 
tered throughout  this  area  are  spindle  cells  and  round  cells.     At  a  and  b  are  giant-cells.     At  c  the  cells  are  so  arranged 
as  to  suggest  a  small  gland.     At  d  is  a  large  cell  bearing  a  strong  resemblance  to  a  squamous  cell. 


The  discharge  had  always  been  free  from  odor.  She  is  positive  that  the  discharge 
never  had  a  urinous  odor. 

"Status  Prsesens. — The  patient's  general  health  was  unimpaired.  Urinalysis 
and  physical  examination  of  the  chest  and  abdomen  were  negative.  There  were 
no  evidences  of  pulmonary  tuberculosis  nor  of  tuberculosis  elsewhere.  Through 
the  discharging  sinus  below  the  umbilicus  a  small  sound  could  be  passed  down- 
ward behind  the  symphysis  pubis. 

"Operation. — The  fistulous  tract,  upon  being  dissected  free,  was  found  to  pass 
downward  from  the  discharging  orifice,  coursing  in  front  of  the  peritoneum,  crossing 
the  space  of  Retzius  and  terminating  in  a  thin  cord  attached  to  the  anterior  bladder 
wall  in  the  median  line  and  near  to  the  vesico-urethral  junction.  Upon  being  split 
open  the  definite  tube-like  structure  was  found  to  be  thin-walled,  showing  no  evi- 
dence of  inflammation  or  other  pathological  condition  except  near  the  external 
discharging  orifice,  where  an  ulcerated  mass  about  2  cm.  in  width  was  situate  upon 
the  dorsal  wall  of  the  tube. 

"Cystoscopic  Examination. — Bladder  distended  with  8  ounces  of  water  for 


654  THE    UMBILICUS    AND    ITS    DISEASES. 

examination:  vesical  sphincter  normal  in  outline;  trigone  normal;  both  ureteral 
openings  and  the  mucosa  surrounding  them  were  normal  as  to  contractility  and 
rhythm.  There  were  no  ulcers,  tubercles,  or  any  other  abnormalities  upon  the  floor 
of  the  bladder.  The  vesical  roof  was  examined  carefully  and  this  portion  of  the 
bladder  was  found  to  be  absolutely  devoid  of  any  ulcer,  tubercles,  opening,  or  any 
other  abnormality  of  the  vesical  mucous  membrane;  and  there  was  not  the  slightest 
hint  of  any  communication  with  the  patent  urachus. 

"•Chemical  and  Microscopic  Urinalysis. — After  operation  as  before  the  urine 
was  normal. 

••Clinical  Course  since  Operation. — "Wound  closed  slowly;   there  have  been  no 


Fig.  269. — A  Tubercle  from  Dr.  Eastman's  Case  of  Tuberculosis  of  the  Urachus. 

This  L=  a  high-power  picture  made  by  Mr.  H.  Schapiro  from  Fig.  267  at  c. 

The  tubercle  is  oval  in  form  and  is  fairly  well  differentiated  from  the  surrounding  stroma.  The  cells  of  the  tubercle 
are  spindle-shaped,  oval,  round,  or  irregular.  In  the  lower  part  of  the  tubercle  is  a  large  giant  cell  containing  a  large 
number  of  nuclei  arranged  chiefly  in  its  center.  The  grouping  of  the  nuclei  in  this  giant  cell  resembles  to  some  extent 
that  usually  found  in  foreign-body  giant  cells,  but  the  picture  as  a  whole  is  strongly  suggestive  of  tuberculosis. 

symptoms  of  any  kind  relating  to  the  genitourinary  organs;  there  is  no  evidence  of 
return  of  the  disease." 

I  wrote  Dr.  Eastman  asking  if  he  could  send  me  sections  of  the  urachus.  This 
he  promptly  did.     An  examination  of  them  shows  the  following: 

The  central  portion  of  the  specimen  consists  of  granular  tissue  containing  a  few 
cells.  It  looks  very  much  like  caseous  tissue  (Fig.  267a).  External  to  this  is  a 
tissue  made  up  of  young  connective-tissue  cells  and  fairly  large  round  cells  with 
small  round  nuclei,  and  beneath  this  a  zone  containing  a  few  giant  cells.  The 
outer  wall  apparently  consists  of  non-striped  muscle  and  connective  tissue  infil- 
trated  with  small  round  cells.  In  this  are  round  or  oval  areas  containing  aggrega- 
tions  of  epithelioid  cells  with  giant  cells  scattered  here  and  there  throughout  them 
[Figs.  208  and  269;.  External  to  this  zone  is  the  surrounding  adipose  tissue.  The 
entire  picture  strongly  indicates  tuberculosis  of  the  urachus. 

Dr.  Benjamin  O.  McCleary  and  Dr.  George  L.  Stickney  have  each  indepen- 
dently demonstrated  tubercle  bacilli  in  the  sections;  consequently  this  is  a  definite 
of  tuberculosis  of  the  urachus. 


INDEX  OF  NAMES 


Note. — As  regards  the  majority  of  the  authors  quoted  I  have  been  able  to  consult  their  original 
publications,  but  in  the  few  cases  in  which  it  was  found  impossible  to  locate  the  original  article, 
I  have  given  the  name  as  it  appeared  in  the  secondary  source  from  which  it  was  secured.  Much 
care  has  been  exercised  to  have  the  names  spelled  correctly,  and  the  fact  that  I  have  at  times 
found  discrepancies  in  the  spelling  of  the  same  name  in  the  different  languages  is  responsible  for 
some  of  the  errors  which  may  still  be  found. 


Adair,  70,  101,  104 

Adams,  171 

Adamson,  286 

Ahlfeld,  1,  33,  101,  221,  463,  464,  480 

Ajello,  403,  404,  411 

Albums,  502,  516,  519 

Albrecht,  162 

Aldis,  298,  300,  306 

Alle  (in  Briinn),  341 

Alric,  487,  488,  495,  513 

Alsberg,  191,  212 

Alsberg  and  Leisrink,  189,  191,  201,  213 

Ammon,  von,  482,  483 

Anderson,  220,  221 

Andrews,  528 

Annandale,  487,  495,  513 

Anthelme,  610 

Ardouin,  189,  192,  212 

Arndt,  223,  227,  236 

Arrou,  569,  570,  571,  577,  622,  627 

Ashhurst,  496,  513 

Aslanian,  428,  429,  430,  436 

Atlee,  539,  547,  565 

Attimont,  412,  415,  418,  422 

Auger,  415,  422 

Auvard,  214,  215,  216,  218,  220 

Auxiron  (d'),  613,618 

Aveling,  458,  635,  636,  646 

Aveling  and  Bland-Sutton,  636,  637 

Avicenna,  328 

Babes,  90 

Baginsky,  90,  315,  317,  326 

Baizeau,  298,  299,  301,  302,  306 

Bajardi,  128 

Baldwin,  547,  565,  569,  570,  571,  572,  577 

Ball,  125,  142,  582,  585,  605 

Ballantyne,  647 

Balluff,  416,  422 

Banti,  272 

Bantigny,  437,  438,  447 

Bantock,  548,  549,  565 


Bardeleben,  617,  618 

Barker,  373,  393,  394,  395,  399,  425,  426,  428 

Barlow,  295,  296 

Bamhardt,  524 

Barraud  and  Tillaux,  403,  410,  412 

Barres,  338,  340 

Barth,  118,  120,  212,  222,  227,  228,  229,  236 

Bartholin,  620,  623 

Barton,  358,  366     ■ 

Basevi,  222,  226,  229,  230,  236 

Battle,  189,  192,  212 

Baumann,  335 

Baumgarten,  86 

Beaucaire,  500 

Beck,  160,  172 

Bedel,  328,  331,  336 

Bednar,  70,  74,  91,  92,  104 

Behrend,  108 

Beilman,  328,  329 

Belfrage,  551 

Bennett,  358,  366 

Beonhardy,  303 

Berard,  297,  298,  337,  343,  344,  345,  458,  513 

Bergeat,  446 

Bergeron,  70,  80,  81,  104 

Bergmann,  von,  416,  587 

Berner,  331,  336 

Bernutz,  294 

Bernutz  and  Guerin,  289 

Bert  and  Viannay,  35,  36,  68 

Bertherand,  315,  316,  317,  326 

Bertherand  and  Merklen,  278,  279,  280,  281, 

282,  284 
Bertrand,  466 

Besson,  400,  403,  404,  411,  422,  425 
Betti,  610 

Beudt,  502,  516,  519 
Bianchi,  328 
Bidone,  125,  142 
Bienaisius,  159 
Biermer  and  Fischer,  265 
Billard,  70,  80 


655 


656 


INDEX    OF    NAMES 


Billroth.  191,  193.  212,  363 

Binnie,  496,  513,  521,  522,  608,  618 

Birch-Hirschfeld,  89,  92 

Birdsall,  559 

Bisehoff,  1S1 

Bize,  162,  163,  172 

Blanc,  125,  126,  132,  142,  160,  172,  292,  457 

Blanc  and  Weil,  125,  142 

Blanchet,  331 

Blandin,  47 

Bland-Sutton,  524,  525,  564,  636 

Bland-Sutton  and  Aveling,  636,  637 

Blasius,  519 

Blin.  222,  223,  226,  229,  236 

Bloodgood  (Joseph  C),  60,  164,  165 

Blum,  247,  260,  278,  283,  284,  288,  350,  356, 

363,  365,  456,  458 
Boehmer,  516,  519 
Boettiger,  67 
Boire,  328 
Boissard,  106 

Boisse,  Codet  de    352,  356,  417,  422 
Bond  and  Pratt,  539,  560,  565 
Bondi,  241.  278,  282,  284,  369,  641,  642,  645, 

646 
Bonvoisin,  403,  405,  411 
Booker,  122,  126,  142 
Borggreve,  328,  332,  336 
Bottini,  328,  332.  336 
Bottomley,  390,  391 
Bouchet,  77 
Bouffleur,  250,  260,  285 
Bourgeois,  580,  581,  586,  605 
Bourne,  564 

Bowman  and  Paget,  506,  507,  513,  514,  625 
Boyer,  353,  574,  620,  621 
Bramann,  338,  339,  342,  343,  578,  581,  582, 

587,  593,  605,  626,  627 
Brehm,  466,  468 
Breschet,  283 
Bricheteau,  298,  300,  306 
Briddon  and  Eliot,  649 
Brindeau,  218,  220 
Broadbent,  191,  193,  212 
Broca,  123,  126,  142,  193,  194,  212 
Brodel,  37,  45,  61,  63,  477.     See  Preface. 
Broussolle,  360,  362,  366,  420 
Bruce,  200 
Brun,  120,  126,  142,  188,  194,  212,  465,  479, 

480 
Briinn  (Alle  in),  341 
Bruns,  170,  367 

Bryant,  358,  366,  456,  549,  565,  572,  577 
Bryant  and  Hine,  297 
Buchwald,  174,  180,  186 
Buckmaster,  68,  100,  104 
Budin,282 


Budin  and  Tamier,  70,  99,  105 

Buettner,  337 

Bufalini,  250,  260 

Buhl,  90,  91 

Bunch,  286 

Bureau,  194,  212,  235,  236,  237 

Burkhart,  400,  403,  411,  412,  416,  422,  428, 

430,  436 
Burnam  and  Kelly,  486 
Busch,  356 

Cabell,  490,  496,  513 

Cabrol,  487,  488,  495,  500 

Cadell,  612,  613,  618 

Cahn,  418 

Cameron,  298,  299,  303,  306 

Camuet,  413,  417,  422 

Cantrell,  276 

Capallaria,  328 

Capette  and  Gauckler,  123,  126,  142 

Cappola,  328 

Carpenter  and  Makins,  136,  143 

Carroll,  541,  549,  565 

Caruso,  479,  480,  528,  531 

Carwardine,  176,  177,  186 

Casali,  332,  336 

Castel,  306 

Cat,  309,  314 

Catoir,  458 

Catteau,  34,  35,  36,  38,  68,  315,  318,  326,  437, 

466,  468,  470,  480 
Cazaban,  298,  299,  303,  306 
Cazin,  1,  33,  118,  120,  160,  162,  163,  172,  174, 

186,  200 
Chandelux,  156,  158 
Chapin,  617,  618 
Charles,  487,  496,  513 
Charon  and  Gevaert,  236 
Charpy,  46,  53,  263 
Chartier,  110,  114 
Chassaignac,  353,  354,  356,  357 
Cheaureau,  523 
Cheyne,  220,  221 
Chiarabba,  278,  285 
Chiari,  226,  229 
Chislett,  258,  260 
Chopart,  597,  610 
Christian,  392 
Chuquet,  400,  411,  425,  426,  428,  437,  438, 

447 
Civiale,  516,  522,  608,  613,  614,  618,  620,  627 
Clado,  369,  390 
Cladus,  328,  350 
Clairmont,  315,  318,  326 
Clark  (A.),  122,  137 
Clark  (J.  G.),  346,  349 
Clement,  338,  343 


INDEX    OF    NAMES 


657 


Clendening,  521 

Cockle,  340 

Codet  de  Boisse,  352,  356,  417,  422 

Coenen,  248,  250,  251,  252,  260,  360,  366 

Cohn,  70,  93,  94,  104 

Colman,  126,  142 

Colmers,    174,    178,    ISO,    186,   187,  238,   239, 

240,  241 
Colombe,  112,  113,  114,  353,  354,  355,  356 
Colombus,  620,  623 
Coniac,  63,  69,  400,  412,  428,  437 
Cornil,  364,  405,  410 
Cornil  and  Ranvier,  422,  425 
Cotte  and  Delore,  549,  565 
Count,  539,  557,  565 
Courvoisier,  337,  343 
Covillard,  614 
Coyne,  479,  480 
Craig,  106,  108,  110,  114 
Crede,  464 
Creulin,  328 
Crooke,  315,  319,  326 
Cruveilhier,  55,  620 
Cullen,  1,  37,  56,  68,  276,  287,  349,  365,  366, 

372,  382,  399,  400,  414,  423,  433,  436,  437, 

440,  442,  447,  469,  470,  475,  637 
Cullen  and  Goldsborough,  347,  349 
Cullen  and  Welch,  541,  542,  543,  544 
Cullen  and  Wilkins,  346,  349 
Cumston,  70,  104,  106,  114 
Cuneo  and  Marcille,  63,  64,  65,  66,  68 
Curran,  288 
Cuvier,  521 


Damalix,  358,  366 

Damaschino,  420,  426,  446 

Dandy,  2 

Dannenberg,  403,  405,  411,  458 

D'Arcy  Power,  459,  460,  480 

Darier  and  Wickham,  269 

d'Auxiron,  613,  618 

Davaine,  328,  329,  330,  336,  345 

de  Boisse,  352,  356,  417,  422 

De  Forest  Willard,  512,  514,  528 

Dejerine,  67 

Dejerine  and  Sollier,  403,  405,  411,  412 

Delageniere,  488,  496,  497,  513,  574 

de  LigneroUes,  297,   298,   337,   338,   339,    340, 

341,  342,  343,  344,  345 
Delore  and  Cotte,  549,  565 
Demarquay,  361,  362,  366,  403,  405,  406,  411, 

444,  448,  458 
Demelin,  106 

Demons  and  Verdelet,  428,  430,  436 
de  Mussy,  428,  431,  436 
Denaire,  332 
43 


Denuce,  145,  146,  147,  148,  149,  150,  155,  162, 

172 
Derville,  252,  260 

Deschin,  118,  120,  189,  195,  200,  212 
Despres,  403,  406,  411 
Deve,  132,  162,  172,  233,  244,  368 
de  Villiers,  116,  117 
Dickinson,  68,  70,  97,  98,  100,  102,  104 
Diemerbroeck,  350,  501 
Diez,  328,  329,  332,  336 
Dittrich,  174,  187 
Diwawin,  127,  142 
Doderlein,  389,  403,  406,  407,  411 
Donatus,  620,  623 
Doran,  541,  549,  550,  551,  552,  553,  565,  570, 

572,  634,  635,  636,  637,  646 
Dorland,  104 
Dossekker,  539,  553,  565 
Douglas,  539,  546,  553.  565,  592 
Dow,  195,  196 

Draudt,  490,  497,  498,  499,  513 
Dregogirone  and  Hamilton,  328 
Dreschel,  144,  146,  153 
Du  Bois,  511 
Dubois,  68,  74 
Duboue,  346,  349 
Ducellier,  405 
Duges,  363 
du  Laurent,  501 
Duplay,  201,  254,  337,  343 
Dupuytren,  120,  126,  188,  194,  283,  344,  345 
Dupuytren  and  Roux,  499,  513 
Durante  and  Porak,  70,  105 
Dussaussay,  470 
Dykes,  623,  627 


Eastmax,  649,  652,  654 

Ebner,  208 

Ehrendorfer,  94 

EhrHch,  369,  370,  374,  382,  383,  384,  399 

Eliot  and  Briddon,  649 

Elliot,  165,  166,  172 

Epstein,  89,  92,  94,  107 

Erdmann,  487,  499,  513,  528 

Eross,  94 

Eustache,  613,  615 

Evans,  68,  69 

Eve,  635 

Eves,  188,  195,  212 

Ewald,  171 


Fabrege,  120,  127,  142,  260 
Fagge,  160 
Faivre,  625 
Falaschi,  610 


658 


INDEX    OF    NAMES 


Falk,  244,  245,  246 

Falkiner,  125 

Fay,  547 

Fay,  Smouse    and  Priestley,  287 

Feli-Plater,  328 

Fenby,  414 

Fere,  253,  260 

Fereol,  289,  291,  296 

Ferguson,  555,  565 

Femel,  501,  607,  609 

Feulard,  314,  326,  400,  411,  417,  422 

Fiasehi,  114,  283,  284,  285 

Finch,  523,  525 

Findlay,  121,  137 

Finger,  332 

Finney  (John  M.  T.),  113 

Fischel,  107 

Fischer,    259,    260,    263,    264,   265,    266, 

312,  314,  326,  345,  417,  422,  491,  570, 

628,  629,  646 
Fischer  and  Biermer,  265 
Fischer-Coin,  356 
Fitz,   118,   120,   159,   160,   161,   163,   171, 

174,  176,  179,  180,  186,  187,  189,  195, 

212,  242,  243,  244,  246,  352 
Flagg,  68,  97,  99 
Florentin,   116,   117,   118,   120,   156,   157, 

488,  500,  513,  608,  618 
Foltz  and  Petrequin,  350 
Forestus,  328 
Forgue,  521 

Forgue  and  Riche,  116,  117,  403,  407,  411, 
Forster,  444,  448 
Forster,  160 
Fort,  420 

Foulerton,  247,  248,  249,  253,  260 
Fournier,  283,  285 
Fourquet,  614 
Fowler,  99,  602 
Fox  and  MacLeod,   142,  241,  268,  270, 

273,401,403,409,411 
Frank,  634,  646 
Freer,  1,  33,  500,  501,  513,  561,  578,  579, 

585,587,588,605,611,618 
Fremont  and  Lannelongue,  116,  117,  124, 

143,  188,  200,  213,  244,  366,  367,  369 
French,  487,  489,  501,  513 
Frincavello,  328 
Fritze  and  Pfeffinger,  346 
Froelich,  157,  197,  212,  500,  608 
Fromantin,  313 
Fronmiiller,  313,  314 
Froriep,  483 
Fry  (Henry),  110,  114 
Fry  f.I.  M.j,  571,  572 
Fulton,  260 
Fnrt  h,  88 


267, 

577, 


172, 
197, 


158, 


458 


271, 

582, 
135, 


Gallant,  106,  114,  466,  478,  480 

Gallet,  444,  445,  448 

Gampert,  214,  215,  216,  220 

Garcin,  108,  111,  114 

Gamier,  457,  458 

Garrigues,  588,  605 

Gauckler  and  Capette,  123,  126,  142 

Gauderon,  39,  45,  46,  51,  69,  290,  291,  296, 

297,  298,  299,  302,  303,  304,  305,  306,  314, 

466,  469,  470,  480 
Gennaro,  595 
Gerdes,  449 

Gernet,  122,  123,  127,  128,  142 
Gerota,  66 
Gertler,  277,  278 
Gesenius,  222,  226,  230,  236 
Gevaert,  198,  212,  222,  231,  236 
Gevaert  and  Charon,  236 
Giani,  122,  128,  142 
Giannettasio,  374,  387,  399 
Gibb,  218,  219,  220,  226 
Giessen,  328 
Gilbert,  254 

Giordano,  403,  407,  411 
Girone,  332 
Glos,  332 

Goddard,  373,  390,  393,  399 
Golding-Bird,  222,  231,  236 
Goldsborough  and  Cullen,  347,  349 
Goldschmidt,  614 
Gonard,  253,  260 
Gosselin,  294 
Gould,  128,  142 
Goupil,  487,  490,  501,  513 
Graf,  491,  501,  513,  580,  588,  605,  630,  646 
Grandidier,  106,  108 
Grawitz,  312,  314 

Green,  366,  373   374,  375,  376,  378,  399 
Greenhill,  350 
Gremillon,  70,  104 
Griffith,  496,  501,  513 
Grinnell,  419 
Gross,  423,  425 
Gruget,  519,  521 
Guattani,  344 
Guelliot,  367,  369 
Guelliot  and  Hue,  366 
Gueneau  de  Mussy,  428,  431,  436 
Gueniot,  499,  502,  513,  514,  519,  521 
Guerin  and  Bernutz,  289 
Gueterbock,  248,  254,  260 
Guiselin,  352,  403,  407,  411 
Guisy,  611,  612,  618 
Guiteras,  325,  326 
Gunthorpe  and  Parsons,  188,  122 
Guobaux,  163 
Guilt,  523,  524,  525 


INDEX   OF    NAMES 


659 


Gusserow,  93 

Guthrie,  21.5,  217,  21S,  220,  226 

Guyon,  390,  454 

Guyot,  469 

Habershox,  319 

Hagendorn,  620,  623 

Haggard,  305,  306,  437,  442,  443,  44S 

Hahn,  2.54,  261 

Haller,  .502,  516,  519 

Halsted  (William  S.),  542 

Hamilton,  70,  80,  328,  330,  333,  336 

Hamilton  and  Dregogirone,   328 

Hannay,  402 

Hansen,  189,  198,  204,  212 

Hanuschke,  629 

Haran,  503,  513 

Harder,  620,  623 

Hart,  428 

Hartmann,  122,  125,  128,  142 

Harttung,  364 

Hartz,  113,  114,  278 

Harvey,  516,  519 

Hastings,  581,  582,  589,  605 

Heaton  198,  212 

Hecking,  328,  333,  336 

Heer,  329,  333 

Heflin,  491,  492,  493,  494,  513 

Heinrich,  314,  326,  577 

Hektoen,  122,  123,  129,  130,  142 

Heller,  171 

Helmreich,  314 

Helmuth,  500,  588 

Helweg,  222,  223,  231,  232,  236 

Helwig,  620,  623 

Hendee,  176,  178,  187 

Henke,  124,  130,  131,  142 

Hennig,  174,  180,  186,  187,  259 

Henoch,  299,  305,  470 

Hertz,  39,  69,  403,  407,  411 

Herzenberg,  382,  399 

Heslop,  563 

Heuer,  541 

Heurtaux,  262,  263,  264,  403,  408,  411 

Heurtaux  and  Jotion,  263 

Hickman,  198,  199,  212 

Hicks,  355 

ffilden,  von,  360,  361 

Hind,  489,  503,  513,  581,  592,  605 

Hinds  393 

Hine  and  Bryant,  297 

Hinsdale,  70,  104 

Hippocrates,  70,  80 

Hirst,  313 

Hoffmann,  491,  518,  519,  522,  525,  621,  627, 

628,  630,  631,  632,  646 
Hollaendersky,  131,  142 


Holmes,  121,  131,  142,  189,  199  212,  223,  232, 

236 
Holt,  116,  117,  124,  131,  132,  142 
Homans,  195 
Hope,  4.59 
Horion,  616 
Hornig   569,  573,  577 
Hosick,  547 
Hryntshak,  107 
Hue,   122,   132,   133,   142,   233,   236,  244,   246, 

368,  369,  487,  503,  513 
Hue  and  Guelliot,  366 
Hue  and  Jacquin,  403,  408,  411 
Huggins,  166,  172,  488,  503,  513 
Hunner,  371,  486 
Hurdon  (Elizabeth),  395 
Hurdon  (Elizabeth)   and  Kelly   (H.  A.),   160, 

161,  162,  172,  297 
Hutchinson,  417,  422 
Hiiter,  174,  187 
Hutinel,  278,  281,  282,  285 
Huttenbrenner,  222,  224,  233,  236 
Hutton,  556 
Hyrtl,  47,  161 


III,  565,  592,  605 
Imbert,  504,  513 
Ippolito,  403,  408,  412 

Jaboulay,  490,  506,  617 

Jacobi,  509 

Jacoby,  189,  199,  212,  487,  504,  513,  611,  618 

Jacquin  and  Hue,  403,  408,  411 

Jahn,  487,  504,  505,  513 

Jaksch,  von,  146,  152 

Jenkins,  106 

Jobert,  2*30 

Johnson,  121,  131 

Johnston,  370 

Johnstone,  564 

Jones  (E.  G.),  370,  373,  395 

Jones  (H.),  164 

Jordan,  167,  172 

Jores,  50,  51,  403,  408,  412 

Josenhans,  346,  349 

Jouon,  263 

Joiion  and  Heurtaux,  263 


Karetvski,  234 

Kaig,  272 

Kaufmann,  449,  450,  451,  453,  4.58,  499 

Keber,  96 

Kehr,  189,  199,  212 

Keibel,  24 

Keith,  312 


660 


INDEX    OF    NAMES 


Kelly,  210,  334 

Kelly  (Howard  A.),  395,  431,  477,  484,  528, 

531,  534 
Kelly  and  Burnam,  4S6 
Kelly  and  Hurdon,  160,  161,  162,  172,  297 
Kennedy,  505,  513 

Kern,  159,  173,  200,  212,  328,  336,  463,  480 
Kidd  and  Patteson,  353,  356 
King,  160,  161,  162,  163,  173,  188,  191,  212, 

222,  223,  224,  226,  233,  236,  244,  245,  246 
Kirmisson,  118,  120,  123,  124,  132,  133,  134, 

143,  200,  212,  616,  618 
Klebs  and  Scharer,  174 
Klopp  and  Sanger,  174,  186 
Knecht,  310,  311,  314 
Koeberle,  356 

Kolaczek,  122,  126,  133,  134,  143 
Kolbing,  222,  223,  233,  236 
Kommerell,  107,  108,  114 
Korte,  200,  213 
Koslowski,  410,  412,  633,  646 
Kostlin,  625,  626,  627 
Kraske,  200 
Krause,  155 
Kronlein,  553 

Kulenkampff,  174,  180,  181,  186,  187 
Kussmaul,  346,  422 
Ktister,  34,  69,  361,  363,  365,  366,  367,  369, 

430,  445,  448 
Kiistner,  122,  132,  134,  136,  143 
Kuttner,  170,  171,  173,  250,  251 

Lage,  425,  426,  428 

Lamb,  563 

Lambert,  70,  95,  104 

Lane,  303 

Lannelongue,  505,  513 

Lannelongue  and  Fremont,  116,  117,  124,  135, 

143,  188,  200,  213,  244,  366,  367,  369 
Largeau,  417,  422 
Larrey,  586 

Lasource  (Leveque),  618 
Lassar,  283 
Launois,  362 
Laurent  (du),  501 
Laurentius,  607 
Lavater,  159 
Lawrence,  393,  460 
Lawton,  352,  353,  354,  355,  356,  357 
Lawton  and  Maunoir,  138 
Lebert,  426 
Le  Blanc,   125,   126,   132,   142,   160,   172,  292, 

157 
Le  Cat,  309,  314 
Leclerc,  338,  342 

Le  Coniac,  63,  69,  400,  412,  428,  437 
Le  Count,  539,  557,  565 


Ledderhose,  1,  3,  33,  116,  117,  190,  204,  213, 

247,  254,  261,  299,  305,  306,  312,  314,  326, 

336,  343,  352,  353,  356,  363,  366,  367,  369, 

400,  412,  418,  422,  425,  466,  468,  470,  479, 

480,  505,  513,  621,  627 
Le  Fort,  420 
Legg,  573,  577 
Legrand,  358,  366 
Leguelinel  de  Lignerolles,  297,  298,  337,  338, 

339,  340,  341,  342,  343,  344,  345 
Leisrink  and  Alsberg,  189,  191,  201,  213 
Le  Roy,  138 

Leroy  des  Barres,  338,  340 
Leuckart,  328,  336 
Levadoux,  39,  45,  46,  47,  48,  49,  50,  51,  52,  53, 

54,  55,  60,  61,  62,  69,  365 
Leveque-Lasource,  608,  609 
Levie,  616,  618 
Lewis,  403,  408,  412 
Lexer,  145,  146,  147,  149,  150,  155,  491,  492, 

497,  513,  574,  577,  580,  581,  582,  592,  605, 

613,  614,  616,  617,  618 
Leydhecker,  357,  454,  458 
Lieberkiihn,  565 
Limange,  358 
Lini,  333 
Linthicum,  113 
Lissner,  450 
Lister,  96 

Littre,  516,  519,  610,  613,  614,  618 
Liveing,  431,  436 
Lohlein,  174,  187 
Lomer,  89 
Longuet,  255 
Longuet  and  Quenu,  63,  69,  400,  412,  437,  446, 

448,  458 
Lorain,  70,  80,  104 
Lotzbeck,  366,  367,  479 
Lowenstein,  124,  136,  160,  161,  173,  222,  223, 

226,  234,  236 
Lowy,  24,  33 

Lucas-Championniere,  215 
Ludwig,  188,  200 
Lugeol,  490,  505,  513 
Luschka,   498,   515,   516,   517,   518,   519,   522, 

526,  531,  553,  621,  627 
Lynker,  618,  619 

Maas,  137,  405 

Macdonald,  539,  540,  558,  559,  565 

Macewen,  409 

MacLeod   and   Fox,    142,   241,   268,  270,  271, 

273,  401,  403,  409,  411 
MacMunn,  447 
Macphail,  333,  336 
MacSwiney,  210,  213,  330,  334,  336 
Magnanini,  136,  143 


INDEX    OF    NAMES 


661 


Mahomed,  244,  245,  246 

Major,  160 

Makins  and  Carpenter,  136,  143 

Mall  (Franklin  P.),  7,  9,  12,  15,  33,  545 

Mallet,  36S 

Mann,  637,  641 

Marcellus,  623 

Marchand,  151 

Marcille  and  Cuneo,  63,  64,  65,  66,  68 

Marjolin,  221 

Maroni,  171 

Marrotte,  294 

Marshall,  201,  213,  593,  605 

Marteau,  328,  334,  336 

Martin,  311,  314,  528 

Marx,  487,  499,  513 

Matthias,  580,  582,  583,  593,  595,  605 

Maunoir,  352,  353,  357 

Maunoir  and  Lawton,  138 

Mauriceau,  70,  80 

Maurin,  292,  296 

Maxwell,  550,  552 

Mayer,  56 

Maygrier,  70,  104 

Maylard,  403,  409,  412 

Mayo  (W.  J.),  475,  477,  528 

McCleary  (Benj.  O.),  654 

McGehee,  295 

McGlannan,  474 

McMurtry,  445,  448 

Meckel,  159,  173,  242,  243,  463,  516,  519,  521, 

525 
Meredith,  139,  140 
Meriel,  50,  521,  522 
Merklen  and  Bertherand,  278,  279,  280,  2S1, 

282,  284 
Mery,  515,  522 

Meyer,  .15,  33,  70,  90,  105,  488,  506,  513 
Meyer-Kempen,  505 
Meynet,  70,  75,  76,  77,  78,  80,  105 
Mikulicz,  von,  504,  593,  594,  595 
Millar,  116,  117 
Millard,  470 
Miller,  94 
MiUer  (C),  545 
Miller  (I.),  437,  439,  440 
MiUigan,  268,  273,  274,  275 
Minelli,  145,  150,  155 

Mintz,  374,  379,  380,  381,  382,  389,  399,  455 
Mirallie,  418,  422 
Mohler,  285 
Monckton,  551 
Monleng,  331 
Monnier,  456 
Monod,   1,  33,  418,  422,  490,   506,   513,  521, 

522,  595,  605,  607,  609,  616,  617,  619,  623, 

627 


Montgomery,  68 

Monti,  89 

Moreau,  519 

Morer,  521 

Morestin,  366,  367,  368,  369,  527,  531 

Morgagni,  159,  163,  466,  468 

Morgan,  582,  595,  596,  605 

Mori,  357,  366 

Morian,  118,  120,  189,  191,  201,  202,  213 

Morris  (M.),  274,  275 

Morris  (R.),  276,  400,  412,  418,  419,  422,  445, 

448 
Morton,  136,  143 
Mracek,  107 
Muller,  91 
Munro,  390,  391 

Murchison,  312,  314,  337,  338,  339,  343 
Mussy  (de),  428,  431,  436 


Nadory,  101,  105 

Nagel,  259,  260 

Nasse,  174,  187 

Naundorf,  524 

Neel,  537 

Nekton,  172,  445,  448,  574 

Neurath,  202,  213 

Neveu,  63,  69,  400,  412,  445,  448,  456,  458 

Newman,  578,  581,  582,  596,  605 

Nicaise,  67,  68,  69,  70,  105,  138,  191,  201,  213, 
247,  254,  255,  261,  288,  289,  291,  292,  296, 
297,  298,  306,  314,  315,  319,  326,  328,  336, 
337,  338,  343,  344,  345,  352,  353,  356,  362, 
365,  366,  453,  458,  461,  466,  468,  480,  519, 
522,  577,  582,  597,  605,  625,  627 

Nicolas,  220,  221,  310,  312,  313,  314 

Nicolich,  328,  334,  336 

Noble,  475 

Noder,  208 

Noel,  291 

Noorden,  von,  369,  370,  374,  382,  387,  388, 
389,  399 

Xoreen,  515,  516 

Nota,  465 

Notta,  255 

Nuck,  466 


O'Briex,  455,  458,  523,  525 

Olshausen,  457,  458 

Ophuls,  118,  120,  223,  226,  227,  234,  237 

Opitz,  528,  531 

Orth,  219,  387 

Osier  (Sir  William),  401,  412 

Ossiander,  328,  335,  336 

Owen,  314,  326 


662 


INDEX    OF    NAMES 


Page,  569,  574,  5<  > 

Paget,  4S7,  507,  508 

Paget  and  Bowman,  506,  507,  513,  514,  625 

Pare,  70,  75,  80,  329,  350 

Park,  189,  202,  213,  255,  261,  319,  326,  528, 
549 

Parker,  122,  136,  143,  400,  401,  403,  409,  412, 
446,  448 

Parsons  and  Gunthorpe,  188,  222 

Pasteur,  96 

Pat  el,  579,  582,  597,  605 

Patir,  201,  202 

Patteson  and  Kidd,  353,  356 

Pauchet,  4S7,  508,  514 

Paul.  328 

Peake,  214,  217,  220,  226 

Pean,  367 

Pelletan,  626 

Penny,  508,  514 

Peraire,  360,  364,  365,  366 

Pernice,  39,  116,  117,  118,  120,  143,  203,  213, 
247,  248,  255,  256,  259,  261,  285,  352,  353, 
356,  357,  359,  363,  364,  366,  369,  400,  402, 
403,  409,  412,  419,  422,  425,  427,  428,  446, 
448,  453,  456,  457,  458 

Perrin,  466,  468,  480 

Pestalozza,  244,  246 

Petersen,  188,  205 

Petit,  509,  514,  611,  619 

Petrequin  and  Foltz,  350 

Peu,  519,  539 

Peyer,  519,  607,  623 

Pfeffinger  and  Fritze,  346 

Phillips,  620,  627 

Phocas,  137,  143 

Pic,  359,  366 

Pierre,  509,  514 

Pinch,  273,  275 

Pineo-Hyannis,  466,  468 

Pinkerton,  70,  105 

Pir-tre,  615 

Pitts,  277 

Plagge,  425,  427,  428,  455,  458 

Platerus,  591 

Poirier,  55,  63,  65 

Pokels,  521 

Polaillon,  247,  256,  261,  359,  456 

Pollak,  70,  74,  105 

Poncet,  343 

Porak,  70,  105 

Porak  and  Durante.  70,  105 

Port,-,],  510,  51'.).  600 

Pouspin,  328 

Poussin,  L88,  194,  20:;.  21:;.  328,  330,  335,  336 

Power,  D'Arcy,  459,  400,  480 

Pratt.  L89,  191,  203,  213 

Pratt  and  Bond.  539,  560,  565 


Prestat,  190,  204,  213,  482 

Preston,  509,  514 

Priestley,  Fay,  and  Smouse,  287 

Pujol,  292 

Putney,  196 

Quaet-Faslem,  188,  189,  191,  204,  213 
Quenu  and  Longuet,  63,  69,  400,  412,  437,  446. 
448,  458 

Racheord,  315,  319,  326 

Raciborski,  468 

Raesfeld,  174,  185 

Railton,  205,  213 

Ransohoff,  307,  308 

Ranvier  and  Cornil,  422,  425 

Raussin,  613,  614,  619 

Recklinghausen,  von,  539,  561,  566 

Reed,  459,  460,  461,  480,  561,  566 

Reichard,  109,  110,  115,  145,  146,  147,  150,  151, 

155 
Reid,  598,  605 
Renard,  598,  605 
Rendu,  297 
Reynolds,  647,  648 
Rhodius,  620,  623 
Ribbert,  105 

Richardson,  160,  161,  173 
Riche  and  Forgue,    116,    117,   403,   407,   411, 

458 
Richelot,  247,  256,  261,  326 
Richet,  46,  47,  48,  51,  52,  338,  339 
Richter,  328,  331,  335,  336 
Riefkohl,  161 
Rille,  283,  285 
Rimbach,  174,  176,  178,  187 
Rintel,  315,  320,  326 
Rippmann,  539,  561,  566 
Ritter,  107 
Rizzoli,  363 
Robb,  572 

Robert,  338,  341,  343 
Robin,  48,  358,  521 
Robinson,  598,  605 
Roesler,  620 
Roger,  444 

Rokitansky,  160,  174,  621,  627 
Rombeau,  321,  326 
Ronis,  298 

Roques,  247,  257,  261 
Rose,  509,  514 
Roser,  144,  145,  149,  151,  155,  239,  241,  582, 

598,  599,  605 
Rosthorn,  von,  145,  146,  151,  152,  155 
Roth,  118,  120,  174,  175,  176,  177,  178,  180, 

181,  182,  183,  185,  186,  187,  189,  191,  250, 

213 


INDEX    OF    NAMES 


663 


Rotter,  631,  633,  646 

Rouget,  257,  261 

Routh,  548 

Roux,  344,  345,  512 

Roux  and  Dupuytren,  499,  513 

Roy,  138 

Ruge,  242,  246 

Runge,  67,  69,  70,  85,  86,  87,  88,  89,  90,  91, 

92,  95,  105,  107,  108,  109,  115,  227,  278,  282, 

285,  461,  480 
Runkel,  174,  187 
Ruysch,  159 

Sachs,  51,  52 

Sadler,  112,  115 

Salge,  70,  105 

Salvisberg,  523,  524,  525 

Salzer,  191,  206,  207,  208,  213 

Sanchez,  329,  335 

Sanderson,  349,  462,  463,  480 

Sandifort,  188,  200 

Sanger  and  Klopp,  174,  186 

Sappey,  50,  63,  358 

Sauer,  208,  209,  213,  360,  366 

Saundby,  563 

Saunders,  624 

Savory,  578,  581,  582,  599,  605 

Scarpa,  460 

Schaad,  185,  186,  187,  239,  539,  547,  562,  566 

Schaffer,  208 

Schapiro,  544 

Scharer  and  Klebs,  174 

Schauta,  645 

Schenck,  591 

Schlesinger,  420,  422,  423,  425 

Schmid,  229 

Schmitz,  315,  321,  327 

Schnellenbach,  581,  582,  600,  606 

Scholz,  539,  562,  566 

Schroeder,  160,  173,  188,  210,  213,  234,  237, 

243,  456 
Schrotter,  309,  314,  322,  324,  327,  335 
Schulze,  188,  200 
Scott,  323,  327 
Segond,  361,  362,  365 
Senn,  528 
Sennertus,  591 

Shattock,  247,  257,  261,  393,  553 
Sheen,  123,  143,  168,  169,  170,  173,  246,  459, 

480 
Sheild,  275 

Shepherd,  189,  210,  213 
Sibert,  108,  111,  115 
Siebold,  234,  237,  328,  331,  336 
Simmons,  174,  333 
Simon,  503,  509,  513,  514,  516,  522,  599,  606, 

610,  613,  615,  619,  620,  627 


Simpson,  121,  137,  143 

Singewald,  433 

Siredey,  292 

Sladen,  276 

Smart,  567 

Smit,  509,  514 

Smith  (F.  B.),  339 

Smith  (F.  R.),  56 

Smith  (J.),  363,  366 

Smith  0T.),  510,  514 

Smith  (T.  B.),  461 

Smith  (W.  A.),  528  t 

Smith  (W.  R.),  647 

Smouse,  Fay,  and  Priestley,  287 

Sollier  and  Dejerine,  403,  405,  411,  412 

Soltmann,  96 

Sottas,  291,  293 

Sourdille,  359,  366,  456,  458 

Spangenberg,  244,  246 

Spiller,  66,  67  ,     . 

Spiller  and  Weisenburg,  67,  69 

Sporing,  331 

Stadfeldt,  510,  514 

Stanley,  646 

Starcke,  609,  619 

Starr,  488,  510,  514 

Stavely,  285 

Steenken,  137,  143 

Stevens,  488,  510,  514 

Stewart,  164,  165,  462,  480 

Stickney  (George  L.),  654 

Stierlin,  210,  211,  213,  244,  487,  510,  511,  514 

Stiles,  331,  336 

Stites,  490,  511,  514 

Stoltz,  68 

Storer,  420,  422 

Stori,  122,  137,  143,  403,  409,  412,  447,  448 

Stowell,  603 

Strada,  145,  152,  155 

Stratz,  47 

Strecker,  112,  115 

Struthers,  160,  173 

St.  Sardi,  336 

Stuart,  108,  112,  115 

Suchannek,  498,  520,  621,  627 

Swain,  524,  525 

Tait,  531,  539,  540,  546,  547,  548,  555,  563. 

564,  565,  566,  636 
Tanchou,  401 
Tannar,  347 
Tansini,  411 
Targett,  637 

Tarnier  and  Budin,  70,  99,  105 
Taylor,  303 
Taylor  (F.  L.),  574 
Taylor  (J.),  108,  111,  112,  115 


664 


INDEX    OF    NAMES 


Taylor  (W.  J.),  247,  257,  25S,  261 

Thacher,  649,  650,  651,  652 

Theremin,  223,  226,  235,  237 

Thiersch,  153 

Thompson,  344,  624 

Tiedemann,  176,  177,  187,  188,  200 

Tikhoff,  137,  143 

Tillaux,  405 

Tillaux  and  Barraud,  403,  410,  412 

Tilling,  188,  200 

Tillmanns,  118,  120, 144, 145, 146,  149,  151,  152, 
153,  154,  155,  163,  173,  234,  242,  246,  314, 
316,  327,  331,  336,  361,  365,  366,  420,  422, 
458,  519,  522 

Timmerman,  582,  600,  606 

Tisserand,  420,  422,  423,  425 

Todd,  620 

Tolet,  620 

Trailer,  328 

Trelat,  310,  314 

Tremontani,  247,  258,  261 

Trendelenburg,  573,  600 

Trepan,  307 

Treves,  160,  173 

Triboulet,  298,  299,  304 

Tricot,  571,  622 

Trogneux,  521,  609,  619 

Trousseau,  70,  74,  75,  77,  80,  105 

Tscherning,  174,  187 

Tuholske,  490,  511,  514 

Turner  (W.),  241,  268 

Tuttle,  651 

Underwood,  70,  80 

Unna,  272 

Unterberger,  600,  601,  606 

Yacher,  340 

Valette,  402,  413,  421,  422 

Vallin,  315,  316,  323,  327 

Vallisnieri,  620 

Vander  Veer,  511,  514 

Van  Heukelom,  144,  145,  149,  152,  155 

Van  Hook,  569,  572,  573,  577 

Van  Home,  466,  468 

Vaughan,  1,  33,  501,  504,  513,  514,  521,  522, 

578,  581,  582,  601,  602,  606 
Vaussy,  200.  291,  293,  294,  296,  297,  306,  569, 

570,  574,  577 
Veiel,  5 is,  522,  524,  525,  526,  531,  621,  627 
Velpeau,  511,  51  t,  521,  574 
Verchere,  446,   H7,  448 
Verdelel  and  Demons,  428,  430,  436 
Verdries,  516,  519 
Verneuil,  25(1,  368 
Vest,  139 
Vetu,  306 


Viannay,  292 

Viannay  and  Bert,  35,  36,  68 

Vidal,  574 

Vidal  de  Cassis,  51 

Villar,  132,  138,  143,  247,  261,  278,  352,  357, 

361,  362,  363,  365,  366,  368,  369,  390,  399, 

400,  407,  412,  420,  422,  425,  426,  428,  454, 

456,  458 
Villiers  (de),  116,  117 
Violbing,  235,  237 
Virchow,  121,  138,  143,  352,  356,  357,  449,  450, 

451,  453,  458,  636 
Vogler,  469 
Voigt,  101 

Volkmann,  248,  359,  402,  409,  419,  457,  577 
Vosburgh,  622,  627 

Wachsmuth,  107 

Wagner,  403,  410,  412 

Waller,  512,  514 

Walshe,  401 

Walter,  515,  516,  518,  519,  522 

Walters,  247,  258,  261,  522 

Walther,  122,  138,  143 

Walton,  67 

Walz,  478,  479,  480 

Ward,  167,  173 

Wassermann,  70,  105 

Watson,  365 

Weber,  107,  145,  146,  147,  154,  155,  356,  357, 

363 
Wehsarg,  454 
Weigert,  154,  181 
Weil  and  Blanc,  125,  142 
Weinlechner,  222,  225,  236,  237 
Weisenburg  and  Spiller,  67,  69 
Weiser,  528,  531,  539,  558,  560,  566,  569,  570, 

575,  576,  577,  578,  582,  602,  603,  604,  606, 

623,  627 
Weiss,  107,  189,  191,  211,  213,  219,  220,  328, 

329,  331,  332,  333,  335,  336,  350 
Welch   (William  H.),  644 
Welch  (William  H.)   and  Cullen  (Thomas  S.), 

541,  542,  543,  544 
Wells,  113,  636 
Wernher,  211 
West,  299,  305 
Westphalen,  113 
Wheaton,  155,  158,  232,  496 
Wickham  and  Darier,  269 
Widerhofer,  67,  86,  87,  88,  91,  92,  461 
Wilkins,  116,  423 
Wilkins  and  Cullen,  346,  349 
Wilks,  167,  173,  211,  213 
Willard,  512,  514,  528 
Willey,  W.  T.,  437,  438,  439 
Williams,  104,  105,  247,  258,  261,  345 


INDEX    OF    NAMES 


665 


Wilms,  445 

Wilson,  492 

Winckel,  von,  449,  450,  452,  453,  458 

Winiwarter,  309,  310,  314 

Winterich,  335 

Witzel,  408 

Wolff,  512,  514,  539,  564,  566,  646 

Worster,  580,  582,  604,  606,  627 

Wrany,  365 

Wulckow,  412,  421,  422 

Wullstein,  369,  370,  374,  384,  385,  386,  387,  399 


Wutz,  498,  515,  519,  520,  521,  522,  526,  527, 

528,  530,  531,  539,  566,  576,  577,  621,  627 
Wyss,  180,  238,  239,  241,  527,  531 

Yates,  462,  463,  480,  512,  514 
Yot,  70,  84,  85,  105 
Young,  616 

Ziehl,  314,  315,  324,  327 
Zumwinkel,  118,  120,  238,  240,  241 


INDEX 


Abdomen,  condition  of,  in  abscess  of  abdominal 
wall  due  to  infection  of  urachal  remains  or 
urachal  cysts,  569 
intestinal  cysts  lying  relatively  free  in,  176 
omphalomesenteric  vessel  lying  free  in,  244 
Abdominal  cavity,  free  bile  in,  localized  jaun- 
dice of  umbilicus  in  presence  of,  307 
cyst  originating  from  remnant  of  omphalo- 
mesenteric duct,  185 
fluid,  escape  of,  from  umbilicus,  287 
tumor  attached  to  inner  surface  of  umbilicus, 
370 
extraperitoneal,  635 
wall,  abscesses  of,  due  to  infection  of  urachal 
remains  or  urachal  cysts,  567.     See  also 
Abscess  of  abdominal  wall. 
cysts  in,   due  to  remnants   of  omphalo- 
mesenteric duct,  238 
defects  of,  clinical  examples,  56 
hematoma  of,  near  umbilicus,  113 
hernise  through  weak  spots  in,  56,  60,  478 
in  new-born,  epidemic  of  erysipelas  of,  74 
inflammatory  changes  in,  umbilical  concre- 
tions  associated   with,   247.      See  also 
Umbilical  concretions. 
layers  of,  in  region  of  umbilicus,  34 
Abscess   breaking    through  into    subumbilical 
space,  265 
fistulous,  of  umbilicus,  252 
in  subumbilical  space,  262 
differential  diagnosis,  265 
treatment,  267 
of  abdominal  wall  due  to  infection  of  urachal 
remains  or  urachal  cysts,  567 
abscess  sac  in,  570 
cases  illustrating,  571 
clinical  course,  569 
symptoms,  569 
treatment,  570 
of  broad  ligament  opening  at  umbilicus,  289 
cases  illustrating,  291 
treatment,  291 
of  fiver  opening  at  umbilicus,  297 
into  subumbilical  space,  265 
of  umbilical  vein  in  an  adult,  295 
of  vermiform  appendix  opening  into  subum- 
bilical space,  266 
opening  of,  at  umbilicus,  296 


Abscess  of  vermiform  appendix,  urachal  cyst 
and,  differentiation,  541,  550 
periprostatic,  opening  at  umbilicus,  288 
sac  in  abscess  of  abdominal  wall  due  to  infec- 
tion of  urachal  remains  or  urachal  cysts,  570 
subumbilical,  tuberculous,  256 
thoracic,  opening  at  umbilicus,  288 
Absence  of  umbilicus,  67 

of  urethra,  escape  of  urine  from  umbilicus 
and,  610 
Accessory  pancreas  situated  at  tip  of  Meckel's 

diverticulum,  162 
Actinomycosis  in  subumbilical  space,  266 
Adair  on  bacteriologic  study  of  umbilical  stump, 

101 
Adenocarcinoma  of  umbilicus,  primary,  402 
age  incidence,  403 
report  of  cases,  404 
sex  incidence,  404 
treatment  of,  404 
Adenoma  of  umbilicus,  124,  125 
Adenomyoma  of  umbilicus,  373 
historic  sketch,  373 
personal  observation,  395 
report  of  cases,  375 
Adipose  hernia  of  umbilicus,  365 

tissue  in  umbilical  region,  disposition  of,  54, 
55 
Allantois,  embryology  of,  1,  16,  21 

patency  of,  16 
Amnion,  embryology  of,  1,  7 

umbilicus,  8,  67 
Amniotic  hernia,  461 

Amputation  of  umbilical  cord,   Buckmaster's 
method,  100 
Dickinson's  method,  98 
Nadory's  method,  101 
Angioma  of  umbilicus,  352 
Animals,  Meckel's  diverticulum  in,  163 
remnants  of  urachus  in,  523 
umbilicus  in,  anatomy  of,  61 
urachal  fistula  in,  523 
Anomphalosis,  100 

Anus  or  rectum,  defective  development  of,  pat- 
ent   omphalomesenteric    duct    associated 
with,  220 
preternatural,  found  in  portion  of  ileum  pro- 
truded at  umbilicus,  217 


667 


liliS 


INDEX 


Aponeurosis  of  umbilical  ring,  lymphatics  of,  66 
Appendix,  vermiform,  abscess  of,  opening  into 
subumbilical  space,  266 
opening  of,  at  umbilicus,  296 
urachal   cyst    and,    differentiation,   541, 
550,  583 
Areola,  umbilical,  68 
Arteries,  omphalomesenteric,  embryology  of,  32 

umbilical,  embryology  of,  26 
Arteritis,  umbilical,  etiology  of,  91 
in  new-born,  89 

complications  of,  90 

erysipelas  of  umbilicus  complicating,  90, 
93 
pathogenesis  of,  91 
prognosis  of,  91 
prophylaxis  of,  92 
symptoms  of,  91 
Artery,  omphalomesenteric,  persistence  of,  in 

bases  of  umbilical  polyps,  244 
Ascites,  cyst  of  urachus  and,  differentiation,  541 
from  a  tumor  depending  from  the  navel  ex- 
ternally, 370 
Atheromatous  cysts  of  umbilicus,  366 

cases  illustrating,  367 
Atrophic  tuberculid  of  umbilicus,  286 


Bacteriologic  study  of  umbilical  stump,  101 
Bile,  free,  in  abdominal  cavity,  localized  jaun- 
dice of  umbilicus  in  presence  of,  307 
Biliary  fistula  at  umbilicus,  423 

with  escape  of  gall-stones,  cases  illus- 
trating, 339 
Bladder,  bleeding  from  urachus  into,  647 
calculus  of,  obstructing  urethra,  and  asso- 
ciated   with     escape    of    urine 
from  umbilicus,  613 
cases  illustrating,  613 
removal  through  umbilical  opening,  625 
cancer  of,  631 

cyst  of  urachus  communicating  with,  578,  582 
exstrophy  of,  482 

case  illustrating,  484 
growth  in,  umbilical  urinary  fistula  associated 

with,  612 
neuroma  of,  urachal  cyst  and,  differentiation, 

541 
Symptoms  in  abscess  of  abdominal  wall  due 
to  infect  ion  of  urachal  remains  or  ura- 
chal cysts,  569 
in   urachal   cavities   communicating  with 
bladder  or  umbilicus  or  both,  579 
urachal    cavities    communicating    with,    578. 
Jso  Urachal  en 
Bladder-wall,  thickened,  cysl  of  urachus  and, 
differentiation,  541 


Bleeding  from  urachus  into  bladder,  647 
Blennorrhea  of  umbilicus  in  new-born,  86 
Body-stalk,  embryology  of,  1,  15 
Brain,  autopsy  findings,  in  umbilical  infections 

in  new-born,  73 
Breasts,  umbilicus,  and  other  parts  of  body, 

apparent  escape  of  urine  from,  618 
Broad-ligament  abscess  opening  at  umbilicus, 
289 
cases  illustrating,  291,  293 
treatment,  291 
Buckmaster's  treatment  of  umbilical  cord,  100 
Burns,  fecal  fistula  at  umbilicus  due  to,  313 


Calculus,  fecal,  discharged  at  umbilicus,  198 
in  umbilical  region,  cases  illustrating,  625 
umbilical,  257.     See  also   Umbilical  concre- 
tions. 
urachal,  482 

associated  with  urachal  remains,  620,  621 
urinary,  associated  with  urachal  remains,  620, 

622 
vesical,  obstructing  urethra  and  associated 
with  escape  of  urine  from  um- 
bilicus, 613 
cases  illustrating,  613 
removal   of,    through    umbilical   opening, 
625 
Cancer.    See  Carcinoma. 
Canquoin's  paste  in  epidemic  of  erysipelas  and 

gangrene  of  umbilicus  in  new-born,  75 
Carcinoma  of  gall-bladder,  carcinoma  of  um- 
bilicus secondary  to,  422 
treatment,  425 
of  intestine,  carcinoma  of  umbilicus  second- 
ary to,  425 
cases  illustrating,  426 
of  ovary,  carcinoma  of  umbilicus  secondary 
to,  428 
cases  illustrating,  429 
of  stomach,  carcinoma  of  umbilicus  secondary 
to,  412 
age  incidence,  412 
cases  illustrating,  415 
gastric  symptoms,  413 
prognosis,  415 
sex  incidence,  412 
trauma  incidence,  412 
treatment,  414 
umbilical  fistula  due  to,  case  illustrating, 
418 
of  umbilicus,  400 
classification,  401 
primary  squamous-cell,  402 
retroperitoneal  carcinoma  associated  with, 
447 


INDEX 


669 


Carcinoma  of   umbilicus,  secondary,   cases  in 
which  source  of  primary  growth  was  not 
determined,  437 
of  urachus,  628 
age  incidence,  628 
developing  years  after  closure  of  congenital 

patent  urachus,  629 
sex  incidence,  628 
of  uterus,  carcinoma  of  umbilicus  secondary 

to,  436 
retroperitoneal,  associated  with  carcinoma  of 
umbilicus,  447 
Carcinomatous  cyst  of  urachus,   multilocular, 

637 
Cavities,  urachal,  communicating  with  bladder 
or  umbilicus  or  both,  578.     See  also  Urachal 
cavities. 
Chancre,  syphilitic,  of  umbilicus,  283 
Cholesteatoma  of  umbilicus,  250,  251 
Cicatrix,  umbilical,  34,  35,  36,  37 

variations  in  relationship  of  peritoneum  of 
umbilicus  to,  45 
Cloaca,  embryology  of,  3 
Coccidia,  269 

Coelom,  embryology  of,  22 
Concretions,  umbilical,  247-259 
Connective-tissue  growths,  benign,  of  umbilicus, 

356 
Cord,  fibrous,  lymphatics  of,  66 

umbilical.     See  Umbilical  cord. 
Cords,  vascular,  of  umbilicus,  disposition  of,  48 
Cow,  urachal  remains  in,  524 
Cushion,  umbilical,  36 
Cutaneous  lymphatics  of  umbilical  region  in 

new-born,  66 
Cyst,  abdominal,  originating  from  remnant  of 
omphalomesenteric  duct,  185 
atheromatous,  of  umbilicus,  366 

cases  illustrating,  367 
carcinomatous,  of  urachus,  multilocular,  637 
dermoid,  of  umbilicus,  253,  254,  256,  257,  258, 
366 
cases  illustrating,  367 
echinococcus,  in  subumbilical  space,  266 

of  umbilicus,  344 
esophageal,  in  new-born,  180 
hydatid,  in  subumbilical  space,  266 

of  umbilicus,  344 
in  abdominal   wall  due  to  remnants  of  om- 
phalomesenteric duct,  238 
intestinal,  174.     See  also  Intestinal  cysts. 
of  central  portion  of  omphalomesenteric  duct, 

185 
of  Meckel's  diverticulum,  179 
of  ovary,  serous  umbilical  hernia  associated 

with,  470 
of  umbilicus,  478 


Cyst  of  umbilicus,  rare  case  illustrating,  645 
of  urachus,  481,  517,  526,  539 

cases  illustrating,  528-538,  547-565 
communicating  with  bladder  or  umbilicus 

or  both,  578 
in  pig,  525 

infection,  abscesses  of  abdominal  wall  due 
to,  567.     See  also  Abscess  of  abdominal 
wall. 
large,  539 

abscess  of  appendix  and,  differentiation, 

541,  550 
age  incidence.  540 
ascites  and,  differentiation,  541 
differential  diagnosis,  541 
fluid  in,  540 
historic  sketch,  539 
necrotic  lymph  in,  540 
neuroma  of  bladder  and,  differentiation, 

541 
non-infected,  cases  illustrating,  547 
ovarian  cysts  and,  differentiation,  541 
pain  in,  540 

peritonitis  and,  differentiation,  541 
sex  incidence,  540 
size  of,  539 
symptoms,  540 

thickened  bladder-wall  and,  differentia- 
tion, 541 
treatment  of,  546 
small,  526 

cases  illustrating,  528-538 
personal  observations  on,  531 
treatment  of,  546 
Wutz's  cases,  528 
treatment,  546 
ovarian,  extra-abdominal  multilocular,  56 
suppurating,  piecemeal  removal,  through 

umbilicus,  306 
urachal  cyst  and,  differentiation,  541 
suppurating,  of  urachus,  case  illustrating,  622 
Cystic  dilatations  at  umbilicus,  144 

sarcoma  of  urachus,  case  illustrating,  635 


Defects  of  abdominal  wall,  clinical  examples,  56 
Depression,  umbilical,  bottom  of,  36 
elevation,  37 
smooth,  36 
inflammation  in,  247 
walls  of,  37 
Dermoid  cysts  of  umbilicus,  253,  254,  256,  257, 
258,  366 
cases  illustrating,  367 
urachal  cavities,  communicating  with  blad- 
der or  umbilicus  or  both  and,  differentia- 
tion, 583 


670 


IXDEX 


Dickinson's  treatment  of  umbilical  cord.  97.  98 
Dilatation,  cystic,  at  umbilicus.  144 

of  Meckel's  diverticulum,  intestinal  cyst  due 
to,  178 
Diphtheria  of  umbilicus.  277 
Diverticulum,  Meckel's.  33,  118,  159.     See  also 
Meckel's  diverticulum. 
umbilical.  55 
Duct,  omphalomesenteric,  cyst  of  central  por- 
tion, 185 
embryology  of,  3,  31 
gastric  mucosa  in  persistent.  144 
intestinal  cysts  developing  from,  119,  176 
obliteration  of,  intestinal  cyst  from,  33 
outer  portion,  persistence  of,  loo 

cases  illustrating.  156 
patent,  33,  188,  214.      See  also  Patent  om- 
phalomesenteric duct. 
persistence  of.  intestinal  occlusion  caused 

by,  128 
prolapse  of,  194 
remnants  of,  33,  118 

abdominal  cyst,  originating  from,  185 
cases  illustrating,  131 
cysts  in  abdominal  wall  due  to,  238 
intestinal  obstruction  due  to,  166 
vitelline.     See  Omphalomesenteric  duct. 
Ducts,  Muller's,  remnants  of.  umbilical  tumors 
containing.  373 


Echinococctjs  cyst  in  subumbilical  space,  266 

of  umbilicus.  344 
Eczema  of  umbilicus,  276 
Embryology  of  allantoic.  1,  16 
of  amnion,  1.  7 
of  body-stalk,  1,  15 
of  cloaca,  3 
of  ccelom,  22 
of  exocoelom.  3.  4.  6.  22 
of  exocoelomic  cavity  26 
of  omphalomesenTork-  arteries.  32 
duct,  3,  31 
vein- 
of  primitive  umbilical  cord,  28 
of  umbilical  arteries,  _''> 
cord.  ■',.  28 
region,  1 
vein-.  26 
vesicle,  10.  14 
--<•]-.  26 
of  urachus,  17 
of  vitelline  duct,  '■',.  :;l 
of  yolk-sac,  1.  10 
Empyema  opening  into  subumbilical  space,  265 
Enlargf-uK-iit  of  prostate,  umbilical  urinary  fis- 
tula associated  wirli.  616 


Enterocystoma,  174,  239 

intramesenteric,  180 
Enteroteratoma  of  umbilicus,  122,  124,  127 
Epidemic  of  erysipelas  of  abdominal  wall  in 
new-born,  74 
of  umbilicus  in  new-born,  75 
duration.  77 
recovery  from,  77 
symptoms,  75 
of  gangrene  of  umbilicus  in  new-born,  75,  80 
diagnosis,  81 
duration,  77 
etiology,  81 
recovery  from.  77 
symptoms,  75,  80 
of  umbilical  sepsis  in  new-born,  95 
Epigastric  glands  of  Gerota,  66 
Erysipelas  of  abdominal  wall  in  new-born,  epi- 
demic of.  74 
of  umbilicus  complicating  umbilical  arteritis 
in  new-born,  90,  93 
in  new-born,  92 
epidemic  of.  75 
duration,  77 
recovery  from.  77 
symptoms,  75 
non-puerperal,  £4 
Esophageal  cyst  in  new-born,  180 
Exocoelom,  embryology  of.  3,  4.  6.  22 
Exocoelomic  cavity,  embryology  of,  23,  26 
Exstrophy  of  bladder,  482 

case  illustrating,  484 
Extra-abdominal  multilocular  ovarian  cyst,  56 
Extraperitoneal  abdominal  tumor,  635 
Extra-uterine  pregnancy,  sac  opening  into  blad- 
der in,  583 
Extroversion  of  Meckel's  diverticulum,  192 


Fascia,  umbilical,  anatomy  of,  46,  47,  51 
relations  of  umbilical  vein  to,  53 
varieties  of.  51 
Fatty  fringes  of  umbilical  peritoneum,  54 
tissue  in  umbilical  region,  disposition  of,  54, 
55 
Fecal  concretion  discharged  at  umbilicus,  198 
fistula  at  umbilicus,  33,  309.     See  also  Fis- 
tula, fecal,  at  umbilicus. 
Fetal  remains,  escape  of,  through  umbilicus,  345 
P'ibroma  of  umbilicus.  357 
cases  illustrating,  358 
Fibrous  cord,  lymphatics  of,  66 

ring,  varieties  of,  47 
Fistula,  33,  88,  118,  144,  155,  188,  214,  222,  247, 
262.  287,  298,  306,  309,  312,  313,  314,  325, 
328,  337,  344,  345,  350,  414,  415,  416,  423, 


INDEX 


671 


459,  468,  470,  481,  487,  491,  .523,  569,  578, 
607,  608,  609,  610,  611,  612,  613,  616,  620, 
622,  625,  629,  649 
Fistula,  biliary,  at  umbilicus,  337,  423 
escape  of  foreign  bodies  from,  350 
of  hydatids,  344 
of  liquor  amnii,  345 
of  purulent  material,  247,  262,  287,  298, 

308,  325,  569,  578 
of  serous  fluid,  459,  468,  470 
of  worms,  328 
fecal,  at  umbilicus,  33,  SS,  1SS,  214,  222,  309, 
312,  313,  314,  32S,  491 
development   of,   in  prolapse  of  intestine 
through     patent     omphalomesenteric 
duct,  222 
due  to  burns,  313 

due  to  carcinoma  of  stomach,  case  illus- 
trating, 418 
due  to  external  injury,  312 
due  to  gangrene,  312 
due  to  ulceration  of  intestine,  310 
historic  sketch,  309 

tuberculous  peritonitis  followed  by,  314, 
317 
autopsy  findings,  316 
cases  illustrating,  317 
differential  diagnosis,  316 
symptoms,  314 
treatment,  316 
gastric,  414,  415,  416 
pseudogastric,  144 
tuberculous,  649 

urachal,  481,  487,  491,  523,  57S,  607,  608,  609, 
610,  611,  612,  613,  616,  622,  625,  629 
Fistulous  abscess  of  umbilicus,  252 
Fitz  on  treatment  of  intestinal  obstruction  due 

to  Meckel's  diverticulum,  171 
Flesh  umbilicus,  67 
Fluid  in  urachal  cysts,  540 

secreted  by  umbilical  polyp  or  fistula,  145 

action  of,  on  skin  surrounding  um- 
bilicus, 146 
serous,  escape  of,  from  umbilicus,  in  case  of 
tuberculous  peritonitis,  470 
Foreign  bodies,  escape  of,  through  umbilicus. 

337,  350 
Fox  and  MacLeod's  case  of  Paget 's  disease  of 

umbilicus,  26S 
Fungus,  umbilical,  121,  124 


Gall-bladder,    carcinoma    of,    carcinoma    of 
umbilicus  secondary  to,  422 
treatment,  425 
opening  at  umbilicus.  626 


I  uJl-stones,  escape  of,  from  umbilicus,  337 

cases  illustrating,  339 
Gall-stones,  escape  of,  umbilical  changes,  33S 
Gangrene,  fecal  fistula  at  umbilicus  due  to,  312 
of  umbilicus,  73 
in  new-born,  87 
epidemic  of,  75,  80 
diagnosis,  81 
duration,  77 
etiology,  81 
recovery  from,  77 
symptoms,  75,  80 
prognosis,  88 
symptoms,  88 
Gastric  mucosa  at  umbilicus,   144.     See  also 

Polyps,  umbilical,  congenital. 
Glands,  epigastric,  of  Gerota,  66 
Granuloma  of  umbilicus,  116 
treatment,  117 

umbilical  polyp  and,  differentiation.  124 
Groove,  umbilical,  51 


Hardening  of  linea  alba  and  umbilicus,  case 

illustrating,  573 
Healing  of  wound  of  umbilicus  in  new-born, 

mild  disturbances  in,  86 
Heart,  autopsy  findings,  in  umbilical  infections 

in  new-born,  72 
Hematoma  of  abdominal  wall  near  umbilicus, 

113 
Hemorrhage,  umbilical,  106.    See  also  Umbilical 

hemorrhage. 
Heredity  as  cause  of  umbilical  hemorrhage,  108 
Hernia,  adipose,  of  umbilicus,  365 
amniotic,  461 
into  umbilical  cord,  459 
of  tip  of  Meckel's  diverticulum,  161 
through  weak  spots  in  abdominal  wall,  56, 

60,  478 
umbilical,  459 

congenital  nipping-off  of  protrusion.  463 
forms  of,  459 
in  adults.  471 

radical  operation  for,  474 
case  illustrating,  476 
treatment.  473 
in  children,  465 

Xota's  operation  for.  465 
in  new-born,  465 
serous,  466 

associated  with  large  cystic  myoma  and 
abdominal  ascites,  470 
with  ovarian  cyst.  470 
cases  illustrating.  468 
clinical  course,  466 
small,  at  birth,  465 


672 


INDEX 


Heurtaux  on  phlegmonous  subumbilical  inflam- 
mation, 262 
Horn,  umbilical,  259 
Horse,  remnants  of  urachus  in,  523 

serum  in  spontaneous  umbilical  hemorrhage 
of  new  born,  110 
Hydatid  cyst  in  subumbilical  space,  266 

of  umbilicus,  344 
Hypertrophy  of  prostate,  umbilical  urinary  fis- 
tula associated  with,  616 
of  umbilicus,  352 


Icterus,  localized,  of  umbilicus,  in  presence  of 

free  bile  in  abdominal  cavity,  307 
Ileum,  volvulus  of,  strangulation  of  Meckel's 

diverticulum  caused  by,  165 
Ileus  due  to  intussusception  of  Meckel's  diver- 
ticulum, 170 
to  persistence  of  omphalomesenteric  duct, 
167 
Infancy,  umbilical  hemorrhage  after,  112 
Infection  as  cause  of  umbilical  hemorrhage,  108 
umbilical,  in  new-born,  70,  93.    See  also  New- 
born, umbilical  infections  in. 
wound,  of  umbilicus,  in  new-born,  85 
Inflammation  in  umbilical  depression,  247 
of  umbilical  vein  in  new-born,  92 

vessels  in  new-born,  88 
of  umbilicus  in  new-born,  87 
subumbilical,  262 
Inflammatory  changes  in  abdominal  wall,  um- 
bilical concretions  associated  with,  247.    See 
also  Umbilical  concretions. 
Intestinal  cysts,  classification,  174 

developing   from    Meckel's    diverticulum, 
176,  177 
from  omphalomesenteric  duct,  119,  176 
due  to  dilatation  of  Meckel's  diverticulum, 

178 
formation  from  obliteration  of  omphalo- 
mesenteric duct,  33 
in  new-born,  180 
lying  between  layers  of  mesentery,  180 

relatively  free  in  abdomen,  176 
symptoms,  186 
treatment,  186 
obstruction  due  to  Meckel's  diverticulum,  163 
adherent  to  umbilicus,  165 
treatment,  171 
due  to  passage  of  intestine  through  a  hole 
in  mesentery  of  Meckel's  diverticulum, 
L69 
due  to  patent  omphalomesenteric  duct,  195, 

201 
due   to   persistence  of  omphalomesenteric 
duct,  128 


Intestinal  cysts  due  to  remains  of  omphalo- 
mesenteric duct,  166 
due    to    remnants    of    omphalomesenteric 

vessels,  244 
due  to  tip  of  Meckel's  diverticulum  becom- 
ing adherent  to  a  distant  point,  168 
in  which  Meckel's  diverticulum  was  free, 

case  illustrating,  163 
of  Meckel's  diverticulum,  177 
Intestine,  carcinoma  of,  carcinoma  of  umbilicus 
secondary  to,  425 
cases  illustrating,  426 
inversion  of  Meckel's  diverticulum  into,  170 
prolapse  of,  through  patent  omphalomesen- 
teric duct,  222.    See  also  Patent  omphalo- 
mesenteric duct. 
strangulation  of,  by  diverticulum  ilei,  163, 

211 
ulceration  of,  fecal  fistula  at  umbilicus  due  to, 
310 
Intramesenteric  enterocystoma,  180 
Inversion  of  Meckel's  diverticulum  into  bowel, 

170 
Ischuria,  a  singular  case  of,  589 


Jaundice,  localized,  of  umbilicus,  in  presence  of 
free  bile  in  abdominal  cavity,  307 

Jelly,  Wharton's,  35 

Joints,  infections  of,  autopsy  findings,  in  um- 
bilical infections  in  new-born,  73 


Kidneys,  autopsy  findings,  in  umbilical  infec- 
tions in  new-born,  72 


Legs,  umbilicus,  and  breasts,  apparent  escape 

of  urine  from,  618 
Ligament,  broad,  abscess  of,  opening  at  umbili- 
cus, 289 
cases  illustrating,  291 
treatment,  291 
Linea  alba  and  umbilicus,  hardening  of,  case 
illustrating,  573 
nigra,  39 
Lipoma  of  umbilical  region,  365 
Liquor  amnii,  escape  of  meconium  into,  through 
umbilicus,  218 
escape  of,  through  umbilicus,  345 
Liver,  abscess  of,  opening  at  umbilicus,  297 
into  subumbilical  space,  265 
autopsy  findings,  in  umbilical  infections  in 
new-born,  71 
Lungs,  autopsy  findings,  in  umbilical  infections 

in  new-born,  71 
Luschka's  observations  on  urachus,  516 


INDEX 


673 


Lymph,  necrotic,  in  urachal  cysts,  540 
Lymphatics,  cutaneous,  of  umbilical  region  in 
new-born,  66 

of  aponeurosis  of  umbilical  ring,  66 

of  fibrous  cord,  66 

of  umbilical  region,  anatomic  study,  62-66 
Lymphocele,  umbilical,  356 


Maggots  in  umbilicus,  260 
Malignant  changes  in  urachus,  628 
Mamelon,  35,  36,  37 
Meckel's  diverticulum,  33,  118,  159 

accessory  pancreas  situated  at  tip  of,  162 
adherent  to  umbilicus,  intestinal  obstruc- 
tion due  to,  165 
cyst  of,  179 

dilatation  of,  intestinal  cyst  due  to,  178 
extroversion  of,  192 
hernia  of  tip  of,  161 
historic  sketch,  159 
in  animals,  163 

intestinal  cysts  developing  from,  176,  177 
obstruction  due  to,  163 

due  to  tip  of,  becoming  adherent  to  a 

distant  point,  168 
due  to,  treatment,  171 
inversion  of,  into  bowel,  170 
length  of,  160 
mesenteric,  162 
mesentery  of,  160 

hole  in,  intestinal  obstruction  due  to  pas- 
sage of  intestine  through,  169 
omphalomesenteric  vessels  accompanying, 

243 
strangulation   of,    caused   by   volvulus   of 

ileum,  165 
umbilical  polyp  associated  with,  138 
volvulus  of,  177.     See  also  Omphalomesen- 
teric and  Vitelline  duct. 
Meconium,  escape  of,  into  liquor  amnii  through 

umbilicus,  218 
Melanotic  sarcoma  of  umbilicus,  457 
Mesentery,  intestinal  cysts  lying  between  layers 
of,  180 
of  Meckel's  diverticulum,  160,  162 

hole  in,  intestinal  obstruction  due  to  pas- 
sage of  intestine  through,  169 
remnants  of  omphalomesenteric  vessels  at,  243 
Milligan's  case  of  Paget's  disease  of  umbilicus, 

274 
Mucosa,  gastric,  at  umbilicus,   144.     See  also 
Polyps,  umbilical,  congenital. 
uterine,  umbilical  tumors  containing,  373 
Mtiller's  ducts,  remnants  of,  umbilical  tumors 
containing,  373 


Multilocular  carcinomatous  cyst  of  urachus,  637 
Myxoma  of  umbilicus,  356 
Myxosarcoma  of  umbilicus,  case  illustrating,427 
telangiectatic,  of  umbilicus,  449 


Nadory's  treatment  of  umbilical  stump,  101 
Necrotic  lymph  in  urachal  cysts,  540 
Nelaton  on  treatment  of  intestinal  obstruction 

due  to  Meckel's  diverticulum,  172 
Nerve-supply,  sensory,  of  umbilicus,  66 
Neuroma  of  bladder,  urachal  cyst  and,  differen- 
tiation, 541 
New-born,  blennorrhea  of  umbilicus  in,  86 
cutaneous  lymphatics  of  umbilical  region,  66 
diseases  of  umbilical  vessels  in,  88 
erysipelas  in,  92 

of  abdominal  wall  in,  epidemic  of,  74 
esophageal  cyst  in,  180 
gangrene  of  umbilicus  in,  87 
prognosis,  88 
symptoms,  88 
inflammation  of  umbilical  vein  in,  92 
vessels  in,  88 
of  umbilicus  in,  87 
intestinal  cyst  in,  180 
omphalitis  in,  87 

septic  pyemia  of  umbilicus  in,  93 
spontaneous  hemorrhage  from  umbilicus,  109 
tetanus  in,  from  umbilical  infection,  95 

symptoms,  96 
ulcer  of  umbilicus  in,  87 
umbilical  arteritis  in,  89 

pneumonia  complicating,  90, 
umbilical  erysipelas  complicating,  90,  93 
hemorrhage  in,  instances  of,  110-112 
hernia  in,  465 
infections  in,  70,  93 
autopsy  findings,  71 
brain,  73 
heart,  72 

infection  of  various  joints,  73 
kidneys,  72 
liver,  71 
lungs,  71 

peritoneal  cavity,  73 
terminal  infections,  73 
umbilicus,  71 
clinical  history,  73 
phlebitis  in,  92 

cases  illustrating,  93 
polyps  in,  120 
sepsis  in,  epidemic  of,  95 
wound  infection  of  umbilicus  in,  85 

of  umbilicus  in,  mild  disturbances  in  heal- 
ing of,  86 


44 


674 


INDEX 


Xota's  operation  for  umbilical  hernia  in  chil- 
dren. 465 


Omphalitis  in  new-born,  87 
Omphalomesenteric    arteries,    embryology    of, 
32 
artery,  persistence  of,  in  bases  of  umbilical 

polyps,  244 
duct,  cyst  of  central  portion,  185 
embryology  of,  3,  31 

intestinal  cysts  developing  from,  119,  176 
obliteration  of,  intestinal   cyst   formation 

from,  33 
outer  portion,  persistence  of,  155 

cases  illustrating,  156 
patency  of,  33,  188,  214.     See  also  Patent 

omphalomesenteric  duct. 
persistence  of,  intestinal  occlusion  caused 

by,  128 
persistent,  gastric  mucosa  in,  144 
prolapse  of,  194 

remnants  of,  33,  118,  144,  159,  174,  188, 
214    222    238    242 
abdominal  cyst  originating  from,  185 
cases  illustrating,  131  - 
cysts  in  abdominal  wall  due  to,  238 
intestinal  obstruction  due  to,  166 
solid  tumor  developing  from,  178 
veins,  embryology  of,  33 
vessels,    accompanying    Meckel's   diverticu- 
lum, 243 
patent  omphalomesenteric  duct,  243 
lying  perfectly  free  in  abdomen,  244 
persistence  of,  242 
historic  sketch,  242 
intestinal  obstruction  due  to,  244 
remnants  of,  131 

at  mesentery,  243    See  also  Meckel's  di- 
verticulum and  Vitelline  duct. 
Ovarian    cyst,    extra-abdominal    multilocular, 
56 
serous  umbilical  hernia    associated  with, 

470 
suppurating,  piecemeal  removal,  through 

umbilicus,  306 
urachal  cysl  and,  differentiation,  541 
Ovary,  carcinoma  of,   carcinoma  of  umbilicus 
-'"••uidary  to,  428 
cases  illustrating,  429 
papilloma  of.  papilloma  of  umbilicus  second- 
ary to,  371 


p's  disease  of  umbilicus,  268 
Fox  and  MacLeod's  case,  268 


Paget's  disease  of  umbilicus,  Milligan's  case, 
273 
radium  treatment,  274 
Pancreas,  accessory,  situated  at  tip  of  Meckel's 

diverticulum,  162 
Papilloma   of   ovary,    papilloma   of   umbilicus 
secondary  to,  371 
of  umbilicus,  360 

cases  illustrating,  361 
secondary  to  papilloma  of  ovary,  371 
Paste,  Canquoin's,  in  epidemic  of  erysipelas  and 

gangrene  of  umbilicus  in  new-born,  75 
Patency  of  allantois,  16 

Patent  omphalomesenteric  duct,  33,  118,  188, 
214 
age  incidence,  188 

and  patent  urachus  in  same  child,  491 
appearance  of  umbilicus,  189 
associated  with  defective  development 
of  rectum  or  anus,  220 
with  imperforate  sigmoid,   221 
cases  illustrating,  191-211 
condition  of  child,  191 

of  skin  around  fistula,  191 
of  umbilical  cord,  189 
discharge  from  fistula,  191 
historic  sketch,  188 
intestinal  obstruction  due  to,  195,  201 
omphalomesenteric  vessels  accompany- 
ing, 242 
opening  into  abdomen  and  discharging 

feces  into  abdominal  cavity,  219 
opening  of,  on  side  of  umbilical  cord,  214, 

215,  216 
prolapse  of  intestine  through,  218,  222 
age  incidence,  222 
autopsy  findings,  226 
cases  illustrating,  226-236 
development  of  umbilical  fistula,  222 
historic  sketch,  222 
results,  226 
treatment,  226 
sex  incidence,  188 
treatment,  191 

with  fecal  matter  escaping  into  liquor 
amnii,  218 
urachus,  congenital,  487.     See  also  Urachus, 
patent,  congenital. 
tuberculosis  of,  649 
Pearl  tumor  of  umbilicus,  250 
Perforate  umbilicus,  201 
Periprostatic    abscess    opening    at    umbilicus, 

288 
Peritoneal  cavity,  autopsy  findings,  in  umbilical 

infections  in  new-born,  73 
Peritoneum  of  umbilicus,  diverticulum  of,  55 
elevation  of,  in  form  of  a  mesentery,  54 


INDEX 


675 


Peritoneum  of  umbilicus,  fatty  fringes,  54 

variations  in  relationship  of,  to  umbilical 
cicatrix,  45 
Peritonitis,  tuberculous,  escape  of  serous  fluid 
from  umbilicus  in,  470 
tuberculous,    followed    by    fecal    fistula    at 
umbilicus,  314.  See  also  Fistula,  fecal,  at 
umbilicus. 
urachal  cysts  and,  differentiation,  541 
with  escape  of  pus  at  umbilicus,  294,  298 
age  incidence,  298 
cases  illustrating,  300 
causes,  299 
clinical  picture,  298 
complications,  299 
differential  diagnosis,  300 
recovery,  299 
symptoms,  298 
Peri-umbilical  fossettes,  55 

veins,  anatomy  of,  50 
Phimosis,   congenital,   with  urinary   umbilical 

fistula,  611 
Phlebitis,  umbilical,  in  new-born,  92,  93 
Phlegmon,  subumbilical,  262 
Pig,  cyst  of  urachus  in,  525 

urachal  remains  in,  524 
Plasmoma,  272 
Pocket,  umbilical,  258 
Polyps,  umbilical,  118,  120,  144 

associated    with    Meckel's    diverticulum, 

cases  illustrating,  125-142,  147 
danger  of,  125 
fluid  secreted  by,  145 

action  of,  on  skin  surrounding  umbili- 
cus, 146 
macroscopic    appearance  of  umbilical  re- 
gion, 145 
microscopic  picture,  145 
multiple,  124 
persistence   of   omphalomesenteric    artery 

in  bases  of,  244 
symptoms  of,  122 
treatment  of,  124 

umbilical  granuloma  and,  differentiation, 
124 
Pregnancy,  extra-uterine,  sac  opening  into  blad- 
der in,  583 
umbilicus  during,  68 
Preternatural  anus  found  in  portion  of  ileum 

protruded  at  umbilicus,  217 
Primitive  umbilical  cord,  embryology  of,  28 
Prolapse  of  intestine  through  patent  omphalo- 
mesenteric duct    222.    See  also  Patent  om- 
phalomesenteric duct. 
Prostate,  enlargement  of,  umbilical  urinary  fis- 
tula associated  with,  616 
Pseudopyloric  mucous  membrane,  144 


Pubes  and  umbilicus,  tumor  between,  481 
Pus,  escape  of,  at  umbilicus,  peritonitis  with, 

298.    See  also  Peritonitis. 
Pyemia,  septic,  of  umbilicus,  in  new-born,  93 


Radical  operation  for  umbilical  hernia,  474 

case  illustrating,  476 
Radium  treatment  of  Paget's  disease  of  um- 
bilicus, 274 
Rectum   or   anus,    defective   development   of, 
patent   omphalomesenteric    duct   associated 
with,  220 
Remnants  of  omphalomesenteric  duct,  33,  118, 
144,  159,  174,  188,  214,  222,  238,  242 
cysts  in  abdominal  wall  due  to,  238.  See 
also  Meckel's  diverticulum. 
of  urachus,  515.    See  also  Urachus,  remnants 

of. 
of  vitelline  duct  at  navel,  129 
Retroperitoneal  carcinoma  associated  with  car- 
cinoma of  umbilicus,  447 
fluid,  escape  of,  from  umbilicus,  287 
Ring,  umbilical,  aponeurosis  of,  lymphatics  of, 
66 
fibrous,  varieties  of,  47 
Round  umbilicus,  35,  36 

worms,  escape  of,  from  umbilicus,  328.    See 
also  Worms,  round. 
Round-cell  sarcoma  of  umbilicus,  457 
Runge  on  wound  infection  of  umbilicus  in  new- 
born, 85 


Sarcoma,  cystic,  of  urachus,  case  illustrating, 
635 
of  umbilicus,  449 
melanotic,  457 
round-cell,  457 
spindle-cell,  453 

cases  reported  as,  454 
of  urachus,  634 
Scar,  umbilical,  34,  35,  36,  37 

variations  in  relationship  of  peritoneum  of 
umbilicus  to,  45 
Sebaceous  umbilical  tumor,  253 
Sensory  nerve-supply  of  umbilicus,  66 
Sepsis,  umbilical,  epidemic  of,  in  new-born,  70, 

95 
Septic  pyemia  of  umbilicus  in  new-born,  93 
Serous  fluid,  escape  of,  from  umbilicus  in  case 
of  tuberculous  peritonitis,  470 
umbilical  hernia.  466,     See  also  Hernia,  um- 
bilical, serous. 
Serum,  horse,  in  spontaneous  umbilical  hem- 
orrhage of  new-born,  110 


676 


IXDEX 


Sinus,  umbilical,  258 

Skin,  umbilicus,  67 

Spindle-cell  sarcoma  of  umbilicus,  453 

cases  reported  as,  454 
Squamous-cell  carcinoma,  primary,  of  umbili- 
cus, 402 
Steer,  urachal  remains  in,  524 
Stomach,  carcinoma  of,  carcinoma  of  umbilicus 
secondary  to,  412 
age  incidence.  412 
cases  illustrating,  415 
gastric  symptoms,  413 
prognosis,  415 
sex  incidence,  412 
trauma  incidence,  412 
treatment,  414 
umbilical  fistula  due  to,  case  illustrating, 
418 
Stones.     See  Calculus  and  Concretions. 
Strangulation  of  intestine  by  diverticulum  ilei, 

163 
Stricture  of  urethra,  umbilical  urinary  fistula 

following,  611 
Stump,  umbilical,  bacteriologic  study,  101 

care  of,  101 
Subumbilical  fossettes,  55 
inflammation,  262 
phlegmon,  262 
6pace,  abscess  in,  262,  265 
differential  diagnosis,  265 
treatment,  267 

of  appendix  opening  into,  266 
actinomycosis  in,  266 
echinococcus  cyst  in,  266 
empyema  opening  into,  265 
hydatid  cyst  in,  266 
liver  abscess  opening  into,  265 
tuberculous  abscess,  256 
tumor,  259 
Sweat-glands,      umbilical     tumors     consisting 

chiefly  of,  369 
.Symphysis  and  umbilicus,  tumors  between,  ura- 
chal remnants  producing.  "j2ti 
Syphilis  as  cause  of  umbilical  hemorrhage,  108 
hemorrhagica  of  umbilicus,  108 
of  umbilicus,  _'7^ 

at  or  shortly  after  birth.  279, 
in  adult,  283 
Syphilitic  chancre  of  umbilicus,  283 


Tapeworms,  escaping  from  umbilicus,  330 
Telangiectatic  myxosarcoma  of  umbilicus.  449 
Tetanu-  in  uew-born  from  umbilical  infection. 
95 
symptoms,  96 
Thoracic  abscess  opening  at  umbilicus,  288 


Transverse  umbilicus,  35,  36 

Tube  and  ovary,  suppuration  of,  with  opening 

at  umbilicus,  292 
Tuberculid,  atrophic,  of  umbilicus,  286 
Tuberculosis  of  patent  urachus,  649 
of  umbilicus,  250,  285 

of  vas  deferens,  umbilical  fistula  due  to, 325 
Tuberculous  abscess,  subumbilical,  256 

peritonitis,  escape  of  serous  fluid  from  um- 
bilicus in,  470 
followed  by  fecal  fistula  at  umbilicus,  314. 
See  also  Fistula,  fecal,  at  iit?ibilicus. 
Tuft,  umbilical,  61 

Tumors,  abdominal,  attached  to  inner  surface 
of  umbilicus,  370 
between  umbilicus  and  pubes,  481,  526 
extraperitoneal  abdominal,  635 
of  umbilicus,  120,  351 
classification,  351 

consisting  chiefly  of  sweat-glands,  369 
containing  remnants  of  M  tiller  s  ducts,  373 

uterine  mucosa,  373 
pearl,  250 
sebaceous,  253 

vascular,  hemorrhage  associated  with,  113 
subunibilical,  259,  539,  567 


Ulcer  of  umbilicus  in  new-born,  87 
Ulceration  of  intestine,  fecal  fistula  at  umbili- 
cus due  to,  309 
Umbilical  areola,  68 

arteries,  embryology  of,  26 
arteritis,  etiology,  91 
in  new-born,  89 
complications,  90 

erysipelas  of  umbilicus  complicating,  90, 
93 
pathogenesis,  91 
prognosis,  91 
prophylaxis,  92 
symptoms,  91 
base,  36 
canal,  47 
cavity.  37 
cicatrix,  34,  35,  36,  37 

variations  in  relationship  of  peritoneum  of 
umbilicus  to,  45 
concretions,  247-259 

cord,  condition  of,  in  patent  omphalomesen- 
teric duct,  189 
embryology  of,  3,  9,  16,  28 
healing  of,  86 
hernia  into,  459 
persistent  vitality  of,  104 
primitive  embryology  of,  28 
treatment  of,  97,  101 


INDEX 


677 


Umbilical   cord,    treatment   of,    Buckmaster's 
method,  100 
Dickinson's  method,  97,  98 

after-care,  99 
Nadory's  method,  101 
cushion,  36 

depression,  bottom  of,  36 
elevation,  37 
smooth,  36 
inflammation  in,  247 
walls  of,  37 
diverticulum,  55 
fascia,  anatomy  of,  46,  47,  51 
defects  of,  46,  52 
relations  of  umbilical  vein  to,  53 
varieties  of,  51 
fecal  fistula,  33,  118,  309 
fistula,  118 

following  puerperal  sepsis,  292 
congenital,  144.    See  also  Fistula,  umbilical, 

congenital. 
due  to  carcinoma  of  stomach,  case  illus- 
trating, 418 
.    due  to  tuberculosis  of  vas  deferens,  325 
fungus,  121,  124 
groove,  51 
hemorrhage,  106 
after  infancy,  112 

associated  with  vascular  tumor,  113 
causes,  108 

general  considerations,  106 
heredity  as  cause,  108 
in  new-born,  instances  of,  110-112 
infection  as  cause,  108 
nature's  method  of  checking,  106,  107 
spontaneous,  in  new-born,  109 
syphilis  as  cause,  108 
time  of  greatest  danger,  106 
treatment,  109 
hernia,  459.    See  also  Hernia,  umbilical. 
hollow,  36 
horn,  259 

infections  in  new-born,  70,  93,  95.     See  also 
New-born,  umbilical  infections  in. 
autopsy  findings  in,  71,  77 
mesentery,  54 
opening,  removal  of  vesical  stones  through, 

625 
phlebitis  in  new-born,  92 
cases  illustrating,  93 
pocket,  258 
polyps,  118,  120,  144 

region,  adipose  tissue  in,  disposition  of,  54,  55 
anatomy  of,  34 
appearance  of,  34 
calculi  in,  cases  illustrating,  625 
embryology  of,  1 


Umbilical  region,  in  animals,  anatomy  of,  62 

layers  of  abdominal  wall  in,  34 

lipomata  of,  365 

lymphatics  of,  anatomic  study,  62-66 
cutaneous,  in  new-born,  66 
tuberculosis  of,  324 
ring,  aponeurosis  of,  lymphatics  of,  66 
scar,  34,  35,  36,  37 

variations  in  relationship  of  peritoneum  of 
umbilicus  to,  45 
sepsis,  epidemics  of,  in  new-born,  70 
sinus,  258 

structures,  abnormal,  24 
stump,  bacteriologic  study,  101 

care  of,  101 
tuft,  61 

tumors,  121,  122,  351 
vein,  abscess  of,  in  adults,  295 

embryology  of,  26 

inflammation  of,  in  new-born,  92 

relations  of,  to  umbilical  fascia,  53 
vesicle,  embryology  of,  10,  14 
vessels,  diseases  of,  in  new-born,  27,  88 

disposition  of,  48 

embryology  of,  26 

inflammation  of,  in  new-born,  88 

obliteration  of,  50 
Umbilicus,  abdominal  tumor  attached  to  inner 

surface  of,  370 
abscess  of  appendix  opening  at,  296 

of  broad  ligament  opening  at,  289 
cases  illustrating,  291 
treatment,  291 

of  liver  opening  at,  297 
absence  of,  67 

adenocarcinoma  of,  primary,  402 
age  incidence,  403 
report  of  cases,  404 
sex  incidence,  404 
treatment,  404 
adenoma  of,  124,  125 
adenomyoma  of,  373 

historic  sketch,  373 

report  of  cases,  375 
adipose  hernia  of,  365 
amnion,  8,  67 
amniotic,  67,  461 
and  linea  alba,  hardening  of,  case  illustrating, 

573 
and  pubes,  tumor  between,  481 
and    symphysis,    tumors    between,    urachal 

remnants  producing,  526 
angioma  of,  352 
appearance  of,  34 

in  congenital  patent  urachus,  488 

in  patent  omphalomesenteric  duct,   189 
appendix,  abscess  opening  at,  296 


678 


INDEX 


Umbilicus,  atheromatous  cysts  of,  366 
cases  illustrating,  367 
atrophic  tuberculid  of,  286 
biliary  fistula  at,  with  escape  of  gall-stones, 

cases  illustrating,  339 
blennorrhea  of,  in  new-born,  86 
breasts,  and  other  parts  of  body,  apparent 

escape  of  urine  from,  618 
calculus  at,  257 
carcinoma  of,  400.     See  also  Carcinoma  of 

umbilicus. 
cholesteatoma  of,  250 
complete,  36 
concretions  at,  247 

connective-tissue  growths  of,  benign,  356 
constituent  elements  of,  36 
cystic  dilatations  at,  144-155 
cysts  of,  478 

of  urachus  communicating  with,  578 
rare,  cases  illustrating,  645 
dermoid  cysts  of,  253,  366 
cases  illustrating,  367 
description  of,  46 
diphtheria  of,  277 
diseases  of,  classification  of,  351 
during  pregnancy,  68 
echinococcus  cysts  of,  344 
eczema  of,  276 

enteroteratoma  of,  122,  124,  127 
erysipelas  of,  complicating  umbilical  arteritis 
in  new-born,  90,  93 
epidemic  of,  in  new-born,  74 
duration,  77 
recovery  from,  77 
symptoms,  75 
non-puerperal,  84 
escape  of  abdominal  fluid  from,  287 
of  fetal  remains  through,  345 
of  foreign  bodies  through,  337,  350 
of  gall-stones  from,  337 
cases  illustrating,  339 
umbilical  changes,  338 
of  liquor  amnii  through,  345 
of  meconium  into  liquor  amnii  through,  218 
of  piece  of  wild-oat  straw  from,  260 
of  retroperitoneal  fluid  from,  287 
of  round  worms  from,  328.    See  also  Worms, 

round. 
of  serous  fluid  from,  in  case  of  tuberculous 

peritofutisj  470 
of  tapeworms  from,  330 
of  urine  from,  absence  of  urethra  and,  610 
in  congenital  patent  urachus,  487 
in  urachal  cavities,  communicating  with 

bladder  or  umbilicus  or  both,  578 
of  vesical  calculi  obstructing  urethra  as- 
sociated with,  613 


Umbilicus,  escape  of  vesical  calculi  obstruct- 
ing urethra,  cases  illustrating,  613 
external  injury  of,  fecal  fistula  at  umbilicus 

due  to,  312 
fecal  concretion  discharged  at,  198 

fistula  at,  309.     See  also  Fistula,  fecal,  at 
umbilicus. 
fibroma  of,  357 

cases  illustrating,  358 
fistula  of,  due  to  tuberculosis  of  vas  deferens, 

325 
Hesh,  67 
gangrene  of,  73,  87 

epidemic  of,  in  new-born,  75,  80 
diagnosis,  81 
duration,  77 
etiology,  81 
recovery  from,  77 
symptoms,  75,  80 
fecal  fistula  at  umbilicus  due  to,  312 
gastric  mucosa  at,  144.    See  also  Polyps,  um- 
bilical. 
granuloma  of,  116 
treatment,  117 

umbilical  polyp  and,  differentiation,  124 
hematoma  of  abdominal  wall  near,  113 
histologic  appearance,  39 
horn  of,  259 
hydatid  cysts  of,  344 
hypertrophy  of,  352 
in  animals,  anatomy  of,  61 
in  urachal  cavities,  communicating  with  blad- 
der or  umbilicus  or  both,  578 
infection  of,  in  new-born,  87,  93 
jaundice  of,  307 
lipoma  of,  365 
lymphocele  of,  356 
maggots  in,  260 
Meckel's  diverticulum  adherent  to,  intestinal 

obstruction  caused  by,  165 
melanotic  sarcoma  of,  457 
myxoma  of,  356 
myxosarcoma  of,  case  illustrating,  427 

telangiectatic,  449 
outside  of,  relation  of,  to  peritoneal  side,  60 
Paget's  disease  of,  268 

Fox  and  MacLeod's  case,  268 
Milligan's  case,  273 
radium  treatment,  274 
papilloma  of,  360 

cases  illustrating,  361 
secondary  to  papilloma  of  ovary,  371 
pearl  tumor  of,  250 
perforate,  201 

periprostatic  abscess  opening  at,  288 
peritoneum  of,  diverticulum  of,  55 
elevation,  in  form  of  a  mesentery,  45 


INDEX 


679 


Umbilicus,  peritoneum  of,  fatty  fringes,  54 

variations  in  relationship  of,  to  umbilical 
cicatrix,  45 
peritonitis  with  escape  of  pus  at,  298.     See 

also  Peritonitis. 
piecemeal   removal   of   suppurating   ovarian 

cyst  through,  306 
polyps  of,   118,   120,   144.     See  also  Polyps, 

umbilical. 
relation  of  outside  of,  to  peritoneal  side,  60 
remnants  of  vitelline  duct.     See  Polyps  and 

Omphalomesenteric  duct. 
round,  35,  36 
round-cell  sarcoma  of,  457 
sarcoma  of,  449.     See  also  Sarcoma  of  um- 
bilicus. 
sensory  nerve-supply  of,  66 
septic  pyemia  of,  in  new-born,  93 
skin,  67 

spindle-cell  sarcoma  of,  453 
cases  reported  as,  454 
syphilis  of,  278 

at  or  shortly  after  birth,  279 
in  adults,  283 
syphilitic  chancre  of,  283 
thoracic  abscess  opening  at,  288 
transverse,  35,  36 
tuberculid  of,  atrophic,  286 
tuberculosis  of,  250,  285 
tumors  of,  120,  247,  351 
classification,  351 

consisting  chiefly  of  sweat-glands,  369 
containing  remnants  of  Mtiller's  ducts,  373 

uterine  mucosa,  373 
sebaceous,  253 
typical,  of  Catteau,  35 
ulcer  of,  in  new-born,  87 
urachal  cavities,  communicating  with,  578. 

See  also  Urachal  cavities. 
urinary  fistula  at.     See  Fistula,  urachal. 
varieties  of  fibrous  ring,  47 
various  forms  of,  35,  37,  47 
vascular  cords,  disposition  of,  48 

tumor  of,  hemorrhage  associated  with,  113 
vertical,  35,  36 
worms  escaping  from,  328 
wound  infection  of,  in  new-born,  85 
Urachal  cavities,  communicating  with  bladder 
or  umbilicus  or  both,  578 
age  incidence,  578 
bladder  symptoms,  579 
cases  illustrating,  585-605 
differential  diagnosis,  583 
discharge  of  urine  from  umbilicus  in, 

581 
pain  in,  580 
sex  incidence,  578 


Urachal  cavities,  communicating  with  bladder, 
symptoms,  578,  582 
treatment,  584 
umbilicus  in,  581 
concretions,  482,  620,  621 
fistula  in  animals,  523 
remains,  515 
Urachus,  481 

bleeding  from,  into  bladder,  647 
calculi  of,  482,  620,  621,  622 

associated  with  urachal  remains,  620,  621 
carcinoma  of,  628 
age  incidence,  628 
developing  years  after  closure  of  congenital 

patent  urachus,  629 
sex  incidence,  628 
carcinomatous  cyst  of,  multilocular,  637 
contents  of,  518 

cystic  sarcoma  of,  case  illustrating,  635 
cysts  of,  481,  517,  539,  578 
cases  illustrating,  547-565 
communicating  with  bladder  or  umbilicus 

or  both,  578 
in  pig,  525 

infection  of,  abscesses  of  abdominal  wall 
due  to,   567.     See  also  Abscess  of  ab- 
dominal wall. 
large,  539 

abscess  of  appendix  and,  differentiation, 

541,  550 
age  incidence,  540 
differential  diagnosis,  541 
fluid  in,  540 
historic  sketch,  539 
necrotic  lymph  in,  540 
neuroma  of  bladder  and,  differentiation, 

541 
non-infected,  cases  illustrating,  547 
ovarian  cysts  and,  differentiation,  541 
pain  in,  540 

peritonitis  and,  differentiation,  541 
sex  incidence,  540 
size  of,  539 
symptoms,  540 

thickened  bladder-wall  and,  differentia- 
tion, 541 
treatment,  546 
multilocular  carcinomatous,  637 
small,  526 

cases  illustrating,  528-538 
treatment,  546 
Wutz's  cases,  528 
suppurating,  ca  e  illustrating,  622 
treatment,  546 
diseases  of,  481 
embryology  of,  16  (allantois) 
fistula,   urinary.     See  Fistula,  urachal. 


680 


INDEX 


Urachus,  Luschka's  observations  on,  516 
malignant  changes  in,  628 
multilocular  carcinomatous  cyst  of,  637 
patent,  congenital,  487 

and  patent  omphalomesenteric  duct  in 

same  child,  491 
appearance  of  umbilicus  in,  488 
cases  illustrating,  495-512 
escape  of  urine  from  umbilicus  in,  487 
general  condition  of  child,  490 
irritation  around  umbilicus,  489 
race  incidence,  490 
sex  incidence,  489 
size  of  umbilical  opening,  489 
symptoms  of,  487 
treatment  of,  490 
tuberculosis  of,  649 
remnants  of,  515 
historic  sketch,  515 
in  animals,  523 

infection  of,  abscesses  of  abdominal  wall 
due  to,  567.    See  also  Abscess  of  abdomi- 
nal wall. 
Luschka's  observations  on,  516 
producing  tumors  between  umbilicus  and 

symphysis,  526 
urachal  concretions  associated  with,  620 
urinary  calculi  associated  with,  620,  622 
Wutz's  observations  on,  519 
sarcoma  of,  634 

cystic,  case  illustrating,  635 
Urethra,  absence  of,  escape  of  urine  from  um- 
bilicus and,  610 
blocking  of,  causes,  610 

umbilical  urinary  fistula  following,  609 
stricture  of,  umbilical  urinary  fistula  follow- 
ing, 611 
vesical  calculi  obstructing,  associated  with 
escape  of  urine  from  umbilicus, 
613 
cases  illustrating,  613 
Urinary  calculi  associated  with  urachal  remains, 
620,  622 
fistula    at    umbilicus,    487,    607.     See    also 
Fistula,  urachal. 
associated  with  enlarged  prostate,  616 

with  growth  in  bladder,  612 
congenital  phimosis  with,  611 
following  blocking  of  urethra,  609 
following  stricture  of  urethra,  611 
when  no  urethral  obstruction  exists,  608 
with  absence  of  urethra,  610 
Urine,   escape   of,    apparent,   from   umbilicus, 
breasts,  and  other  parts  of  body,  618 
from  umbilicus,   absence  of  urethra  and, 
610 
in  congenital  patent  urachus,  487 


Urine,    from    umbilicus,    in  urachal    cavities, 
communicating  with  bladder  or  um- 
bilicus or  both,  581 
vesical  calculi  obstructing  urethra  asso- 
ciated with,  613 
cases  illustrating,  613 
Uterine  mucosa,  umbilical  tumors  containing, 

373 
Uterus,  carcinoma  of,  carcinoma  of  umbilicus 
secondary  to,  436 


Valve,  Wutz's,  521 

Vas  deferens,  tuberculosis  of,  umbilical  fistula 

due  to,  325 
Vascular  cords  of  umbilicus,  disposition  of,  48 
Vein,  umbilical,  abscess  of,  in  adult,  295 
inflammation  of,  in  new-born,  92 
relations  of,  to  umbilical  fascia,  53 
Veins,  omphalomesenteric,  embryology  of,  33 
peri-umbilical,  anatomy  of,  50 
umbilical,  embryology  of,  26 
Vermiform  appendix,  abscess  of,  opening  into 
subumbilical  space,  266 
opening  of,  at  umbilicus,  296 
urachal  cyst  and,  differentiation,  541, 
550 
Vertical  umbilicus,  35,  36 
Vesical.     See  Bladder. 
Vesicle,  umbilical,  embryology  of,  10,  14 
Vitelline  duct,  embryology  of,  3,  31.     See  also 

Omphalomesenteric  duct. 
Volvulus  of  ileum,  strangulation  of  Meckel's 
diverticulum  caused  by,  165 


Wharton's  jelly,  35 

Wild  oat  straw,  escape  of  piece  of,  from  um- 
bilicus, 260 
Worms,   escape  of,  from  umbilicus,  328,  330 
cause  of  fistula,  329 
historic  sketch,  328 
report  of  cases,  331 
symptoms,  329 
treatment,  330 
Wound  infection  of  umbilicus  in  new-born,  85 
Wutz's  cases  of  small  urachal  cysts,  528 
observations  on  urachus,  519 
valve,  521 


Yolk-sac,  embryology  of,  1,  10 


Zinc  chlorid  in  epidemic  of  erysipelas  and  gan- 
grene of  umbilicus  in  new-born,  75 


C89 
1916 
Cullen 

Umbilicus  and  disease. 


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